UNITED LINCOLNSHIRE HOSPITALS PATHWAY OF CARE FOR DIABETIC

KETOACIDOSIS IN ADULTS
(INCLUDES INSULIN PRESCRIPTION, ADMINISTRATION AND MONITORING RECORD)
Site (please circle) LCH PH GDH Louth PATIENT DETAILS (Addressograph)
Date of Admission Name

DRUG ALLERGIES and SENSITIVITIES Date of Birth

Must be completed and signed for BEFORE a drug can be administered NHS Number

If NO KNOWN ALLEGIES / SENSITIVITES, tick box

If YES please state drug(s) AND effect(s) Ward Consultant

Drug(s) Effect(s)

Weight (actual) ___________Kgs Date ________

Weight (estimate) ___________Kgs Date ________

Patient/Carer GP Medical Notes

Source(s) of information (Circle)
Nursing Home Other (state) Date of Diagnosis _____________ Time _________

Print name & sign Designation Date

THIS CHART IS FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS IN ADULTS (OVER 18 YEARS) ONLY.
USE PAEDIATRIC PATHWAY FOR AGES 16-17. It is to aid the management of diabetic ketoacidosis during the first
24 hours (occasionally longer). The DKA protocol is on the reverse of chart. Once the metabolic disturbance has
been corrected patients must have their diabetes treatment prescribed on the ULH adult insulin prescription chart.
DIAGNOSIS OF DKA ESSENTIAL INVESTIGATIONS
(all three criteria must be present) Arterial puncture NOT routinely needed
Criteria Result  U+E, creatinine, blood glucose.
 Venous bicarbonate, pH and potassium using gas analyser
Capillary blood glucose > where available (to allow early potassium replacement
11mmol/l or known DM. ..........mmol/l while awaiting lab results)
Capillary blood ketones  ECG/CXR/MSU/blood cultures/pregnancy test depending
> 3mmol/l .............. on clinical suspicion.
Raised WCC and serum amylase are common in DKA and do
Venous bicarbonate not usually suggest pancreatitis
≤15mmol/l or pH ≤ 7.30. ..............

IMMEDIATE TREATMENT
START IN ED / ASSESSMENT UNIT ORCURRENT LOCATION. DELAY IN TREATMENT MAY BE FATAL.
1. Insert two IV cannulae. Follow ULHT IV Access policy if unable to secure IV access.
2. 1L 0.9% sodium chloride IV infusion over 1hr if systolic BP>90 (If systolic BP <90 give infusion of 500ml 0.9%
sodium chloride over 10-15 minutes. Repeat while waiting for senior review).
3. Start IV insulin infusion ( using ready-made insulin infusion syringe) at 0.1 units/ kg / hr (estimated or actual
weight) at a maximum rate of 15 units per hour

REFER FOR URGENT ICU REVIEW if: GCS on admission <8 or Patient obtunded and unable to maintain
airway or Cardiovascular compromise or hypokalaemia on admission (<3.5mmol/l).
Consider ICU review if clinically not improved after 60 minutes of treatment on the DKA pathway such as
Venous bicarbonate < 5 mmol/l or pH <7.0, blood ketones >6 mmol/l. GCS <12, pregnancy, elderly, heart or kidney
failure, other serious co -morbidities, sats <92% on air, systolic BP <90 mmHg, pulse >100 or <60 Anion gap >16
Consider CVP/urinary catheter if evidence of poor LV or renal function. Consider NG tube if drowsy/ vomiting

REFER TO THE DIABETES TEAM AS SOON AS THE TREATMENT IS COMMENCED

Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021
 PATIENT NAME Weight in KG Insulin dose units per hour
INSULIN
NHS number 50-59 5
FIXED RATE 60-69 6
70-79 7
80-89 8
INTRAVENOUS INSULIN PRESCRIPTION 90-99 9
Insulin Infusion: 100-109 10
Ready-made insulin infusion syringe (50 units soluble insulin in 110-119 11
50ml sodium chloride 0.9%). 120-129 12
Use a non-return device to administer. 130-139 13
Commence fixed rate IV Insulin infusion at 0.1 unit/kg/hour based on 140-149 14
estimate of weight (e.g. 60 kg = 6units/hour) up to a maximum starting >150 15 (higher dose only on
dose of 15 units/hour. advice of Diabetes Team)
If treatment targets are not met (see box 6 on reverse of chart) the insulin
infusion rate may need to increased by 1 unit/hour every hour.

Intravenous insulin Prescriber Prescriber Bleep/contact

Date/Time
infusion rate (units/hour) signature name (print) number

Starting rate

Change 1

Change 2

INSULIN INFUSION RECORD Nursing staff must keep this record below
Ready-made insulin Date Time Infusion Started by Checked by Time infusion
infusion syringe started stopped

REGULAR SUBCUTANEOUS LONG ACTING INSULIN PRESCRIPTION

If patient normally takes long acting Insulin (Abasaglar, Lantus, Levemir, Tresiba, Toujeo, Humulin I, Insulatard,
Insuman Basal) it should be continued at the usual dose and time(s). PRESCRIBE EVEN IF THE PATIENT IS NOT
EATING OR DRINKING. Newly diagnosed patients should start Abasaglar at 22:00 at a dose of 0.2 units per Kg body
weight (e.g. 60kg=12units Lantus once daily at 22:00). WHEN THE PATIENT TRANSFERS TO THEIR USUAL
INSULIN THIS PRESCRIPTION MUST BE CANCELLED AND TRANSFERRED TO THE ADULT INSULIN CHART.
PATIENTS ON INSULIN PUMP SHOULD CONTINUE WITH BASAL RATES IF THE RATES ARE KNOWN.
ENTER INSULIN NAME ADMINISTRATION
TIME(S) Pharmacy:
Dose 1 Change 1 Date

Dose
Units Units
Prescribed by Date Prescribed by Date Sign/
Bleep Bleep
check

Dose
Units Units
Prescribed by Date Prescribed by Date Sign/
Bleep Bleep
check

Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021
 PATIENT NAME NHS number
INTRAVENOUS FLUID PRESCRIPTION
IV FLUID (see box 7 ON REVERSE) If systolic blood pressure <90 give POTASSIUM (K
+)
1L 0.9% sodium chloride over 1hr then infusion of 500ml 0.9% sodium Use Sodium Chloride 0.9% with added Potassium
1L 0.9% sodium chloride over 2 hr then Consider chloride over 10-15 minutes and depending on Serum Potassium levels
1L 0.9% sodium chloride over 2 hr then repeat while seeking senior
potassium review. Plasma K+ Addition
1L 0.9% sodium chloride over 4 hr > 5.5 None
Continue 0.9% saline as needed, to restore circulating volume. When glucose (BG) ≤ 5.5 40 mmol potassium per litre of Sodium Chloride
<14 mmol/l administer 10% glucose at 125ml/hour alongside 0.9% sodium Seek senior review if K+is <3.5. Do not add prior to the 2
chloride (+Potassium Chloride) using a second cannula. Adjust glucose rate in hour bag unless K+ <3.5 and precautions for rapid IV
50ml/hour increments to maintain glucose in the range of 8-14 mmol/l. Take care not to potassium are followed. Use results from venous blood gas
fluid overload susceptible patients (Elderly, kidney/heart problems and patients under 25 where available to allow early potassium replacement.
yrs of age).
INTRAVENOUS FLUID PRESCRIPTION ADMINISTRATION RECORD
When glucose < 14 mmol/l , continue 0.9% saline and
Volume ADD 10% dextrose
Potassium 125ml/hrPrescriber
Duration or Start Finish
Date Route Infusion fluid Chloride Batch No. Signature Signature
(ml) rate Signature/Name Time Time
mmol/L
IV 0.9% Sodium chloride 1000 ml 1000ml/hour

IV 0.9% Sodium chloride 1000 ml 500ml/hour

IV 0.9% Sodium chloride 1000 ml 500ml/hour

IV 0.9% Sodium chloride 1000 ml 250ml/hour

If BG < 14 125 - 275

IV 10% Glucose 1000 ml
mmol/L ml/hour

Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021
 PATIENT NAME
SERIAL RESULT CHART NHS number

See box 11 on reverse for frequency of laboratory monitoring

SERIAL RESULTS (Time from onset)
Fill in all lab and gas results as available
Date Time Time Time Na K Urea Creatinine eGFR pH HCO3 Lab
(Due) (actual) (133-146 (3.5-5.3 (2.5-7.8 (Male 64-110, (>90) (7.35- (22- Blood
mmol/l) mmol/l) mmol/l) female 50-98) 7.45) 29) Glucose
0 min

1hr X X X
2hr

4hr X X X
6hr

12hr

24hr

Haemoglobin (Male Bilirubin (0-21) CXR

135-169, Female 115-148)
WCC (4.5-13.0) ALT (0-37) ECG
Neutrophils (2.0-7.5) ALP (30-130)
Platelets (140-400) Alb (35-50) Urine dip
CRP (0-10)

AFTER RECOVERY
ALL PATIENTS MUST BE REFERRED TO THE DIABETES TEAM AS SOON AS POSSIBLE
AFTER DIAGNOSIS.

The patient should be transferred to subcutaneous insulin when their metabolic parameters have normalised (venous
pH >7.30 and blood ketones <0.6 mmol/l) and they are able to eat and drink normally. In the majority of patients this
should be within 12-24 hours. Patients with previously known diabetes should be started back on their usual insulin
regimen (see box 12 on reverse). Newly diagnosed patients should be started on subcutaneous insulin and referral
made to the diabetes team.
After recovery the intravenous insulin should be stopped 1 hour after the next subcutaneous dose of insulin
has been given :
Basal bolus –next meal
BD mixed insulin – breakfast or evening meal
If the patient is not eating and drinking and metabolic parameters have normalised (venous pH >7.30 and blood
ketones <0.6mmol/l) they should be started on a variable rate insulin infusion (VRII). This must be prescribed on the
ULH adult insulin prescription chart (details of variable rates are on the chart).

1 hourly blood ketone testing may be stopped once 2 readings of < 0.6mmol/l have been recorded. Monitor
blood ketone levels 4 hourly whilst on VRII. Recommence hourly monitoring if blood ketones rise above
0.6mmol/l.
Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021
 PATIENT NAME

INTRAVENOUS INSULIN AND NHS number

BG MONITORING RECORD SHEET

When you have checked or changed the insulin infusion rate, initial the box.
Monitor capillary glucose and blood ketones hourly. If blood ketones are not falling by > 0.5mmol/L/hour or the
glucose is not falling by > 3mmol/L/hour (until<14 mmol/L), check plasma glucose. Check that insulin infusion pump is
working and connected and that correct residual volume is present (i.e. to check for pump malfunction) If pump
working satisfactorily seek senior medical review and increase insulin infusion rate by increments of 1 unit/hr until
ketones falling by 0.5mmol/l per hour

Insulin infusion Insulin infusion (continued)

Rate Check 1 Check Blood Rate Check 1 Check 2 Blood

Date Time BG Date Time BG
Unit/hr sign 2 sign ketones Unit/hr sign sign ketones

Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021
 United Lincolnshire Hospitals Management of Diabetic Ketoacidosis in Adults
If in doubt call someone more senior. KETOACIDOSIS CAN KILL

1. DIAGNOSIS 2. ESSENTIAL INVESTIGATIONS

All 3 required Arterial puncture NOT routinely needed
1. Raised blood glucose >11mmol/l  U&E, creatinine, blood glucose
2. Capillary ketones >3mmol/l
3. Venous bicarb ≤15mmol/l and/or venous pH ≤7.30  Venous bicarbonate, pH and potassium using gas
analyser where available (to allow early potassium
3.SEVERITY replacement while awaiting lab results)
Blood glucose is NOT a guide to severity. The
 ECG/CXR/MSU/blood cultures/pregnancy test depending
presence of one or more of these indicate severe on clinical suspicion
DKA
Venous bicarb < 5mmol/l or pH <7.0, Blood ketones Raised WCC and serum amylase are common in DKA and do
>6, Hypokalaemia (<3.5) on admission, GCS <12, not usually suggest pancreatitis
SpO2 <92% on air, Systolic BP <90mm Hg, Pulse
rate >100 or <60, Anion gap {(Na + K) – (Cl + HCO3)}
above 16

4.IMMEDIATE TREATMENT. Start in A&E or current location. Delay in starting treatment may be fatal
1. Insert IV cannula
2. 1L 0.9% sodium chloride infusion over 1 hour if systolic BP >90 (if systolic BP <90 give infusion of 500ml 0.9% sodium
chloride over 10-15 minutes and repeat while seeking senior review)
3. Start IV insulin infusion using a ready-made insulin infusion syringe (50 units soluble insulin in 50ml sodium chloride 0.9%).
at 0.1 unit/kg/hour based on actual or estimated body weight .

5.TRANSFER URGENT CRITICAL CARE/ HDU REVIEW if any of : Severe DKA, blood ketones >6 mmol/l. GCS <12,
pregnancy, elderly, heart or kidney failure, other serious co morbidities, sats<92% on air, systolic BP <90 mmHg, pulse >100 or
<60, hypokalaemia on admission (<3.5mmol/l)
Otherwise treatment should be provided on Admission unit or designated diabetes medical ward.

6.INSULIN 7. IV FLUID 8. POTASSIUM

Fixed rate insulin 0.1 units/kg/hour 1L 0.9% sodium chloride over 1 hr then Plasma K Addition
CONTINUE long acting insulin 1L 0.9% sodium chloride*over 2 hr then > 5.5 None
Treatment targets 1L 0.9% sodium chloride*over 2 hr then ≤ 5.5 40 mmol Kcl/litre of
- Blood glucose fall of 1L 0.9% sodium chloride*over 4 hr Sodium chloride
>3mmol/L/hour (*Consider Potassium– see box 8) Seek senior review if K is <3.5
- Capillary ketones fall of Continue 0.9% sodium chloride Do not add prior to 2 hour bag unless
>0.5mmol/L/hour (+Potassium) as needed, to restore +
K <3.5 and precautions for rapid IV
- Venous bicarbonate rise of >3 circulating volume. When blood glucose +
K followed.
mmol/L/hour <14mmol/l continue with 0.9% sodium Use results from venous blood gas to
chloride (+Potassium) and ADD 10% allow early potassium replacement.
NOT IMPROVING? CHECK: glucose 125ml/hr. Adjust rate in 50 ml
Pump operation, patency of cannula, increments to maintain glucose in range 9. BICARBONATE - ITU only
patient weight. Reassess for of 8 – 14 mmol/l. Take care not to fluid Rarely required
concomitant illness. Consider lactic overload susceptible patients (eg elderly Give only on direction of consultant
acidosis. or adolescent) or those with cardiac or endocrinologist or intensivist.
INCREASE rate of insulin infusion renal dysfunction Consider only for patients with
by 1 unit/hour every hour. Check Chloride if acidosis persists and pH<7.0 who are not responding to
Discuss with consultant or SpR seek consultant advice optimal treatment

10. CLINICAL MONITORING 11. LABORATORY MONITORING

Reassess patient hourly for first 4-6 hours, Regular clinical and biochemical review needed during first 24 hours
frequently thereafter 0 hr 1 hr 2 hr 4 hr 6 hr 12 hr 24 hr
Check vital signs at least hourly Glucose       
Monitor capillary glucose and ketones Potassium       
hourly
Consider CVP/urinary catheter if clinical
Creatinine     
evidence of poor LV or renal function
Bicarbonate       
Consider NG tube if drowsy or vomiting Ketones Hourly capillary ketones
REMEMBER REASSES THE PATIENT Arterial gas If sats <94% or arterial line in situ

12. AFTER RECOVERY REFER TO THE DIABETES TEAM

Transfer to sc insulin when patient able to eat and drink normally and All patients should be referred immediately
venous pH>7.30 and blood ketones <0.6mmol/l after treatment started.
Stop IV infusion 1 hour after next sc injection(See Page 4)

Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021
IMMED PATHWAY OF CARE FOR DIABETIC KETOACIDOSIS IN ADULTS
ACTION CARD CHECK LIST (Initial, date and time the box)

IMMEDIATE MANAGEMENT 0-60 MINUTES

ACTION 1: CONFIRM DIAGNOSIS (Box 1, page 6)

ACTION 2: ASSESS SEVERITY

SIGNS OF SEVERE DKA: Call Medical Registrar and Inform ITU (Box 3, page 6)

IS THE PATIENT SHOCKED?

YES: Give Sodium chloride 0.9% 1 litre intravenously over 15 minutes and reassess. If SBP< 100 mm HG,
give another 500 ml over 15 minutes

NO: Give 1 litre 0.9% Sodium Chloride over 1 hour (Box 7, page 6)

ACTION 3: BASELINE ASSESMENT AND INVESTIGATIONS (Box 2 , page 6)

ACTION 4: CHECK AND TREAT PRECIPITATING FACTORS:

Infection, Stress, Non Compliance, Idiopathic cause, Steroids, Alcohol, Pregnancy and Pump failure

ACTION 5: INSULIN

Prescribe Intravenous Insulin at the specified rate (Box 6, page 6)

Weight: Kg Initial Rate: ml/hr

Prescribe Long acting Insulin

ACTION 6: POTASSIUM REPLACEMENT (Box 8, page 6)

Prescribe Potassium from the SECOND Intravenous Fluid bag on wards as per protocol

ACTION 7: REASSES PATIENT

Problem Suggested Action

Hypotension (SBP<100) Fluid challenge and Catheterise

Persistent Vomiting or reduced GCS Nasogastric tube

SaO2 <94% on air CXR and ABG

Ketones not falling by >0.5mmol/L/hour Increase the rate of Insulin by 1 unit/hour

Persistent acidosis Check Renal functions and consider other causes

ACTION 8: REFERRAL TO DIABETES IN PATIENT TEAM

ACTION9: OTHER MEDICATIONS

Stop Dapagliflozin, Canagliflozin and Empagliflozin and Withold metformin

Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021
 MANAGEMENT CHECKLIST 60 MINUTES TO 6 HOURS

ACTION 1: MONITORING (Box11, page 6)

CBG and Ketones VBG U&E Fluid Balance NEWS

Hourly 1,2,4 and 6 hours 2 and 6 hours Hourly Hourly and as appropriate

ACTION 2: IV FLUIDS (Box7, page 6)

Sodium chloride 0.9% +/- Potassium Chloride 2 hourly

Sodium chloride 0.9% +/- Potassium Chloride 2 hourly

Sodium chloride 0.9% +/- Potassium Chloride 4 hourly

Add 10% Glucose 125 to 250 ml/ hour if CBG<14.0 through an additional IV line.

ACTION 3: REASSES PATIENT

NEWS, Urine output, GCS,

ACTION 4: TREATMENT TARGETS (Box 6, page 6)

- Blood glucose fall >3mmol/L/hour

- Capillary ketones fall >0.5mmol/L/hour
- Venous bicarbonate rise >3 mmol/L/hour
If not achieved CHECK Pump operation, patency of cannula, patient weight. Reassess for Concomittant illness and
Lactic acidosis. INCREASE rate of insulin infusion by 1 unit/hour every hour. Discuss with consultant or SpR

MANAGEMENT CHECKLIST 6 HOURS TO 12 HOUR

ACTION 1: IV FLUIDS

Sodium chloride 0.9% +/- Potassium Chloride 4 hourly

Sodium chloride 0.9% +/- Potassium Chloride 6 hourly

Add 10% Glucose 125 to 250 ml/ hour if CBG<14.0 through an additional IV line.

ACTION 2: MONITORING

CBG and Ketones VBG U&E Fluid Balance NEWS

Hourly 6 and 12 hours 12 hours Hourly Hourly and as appropriate

MANAGEMENT CHECKLIST BEYOND 12 HOURS

ACTION 1: RESOLUTION OF DKA

Transfer to sc insulin when patient able to eat and drink normally and venous pH>7.30 and blood ketones
<0.6mmol/l
Stop IV infusion 1 hour after next sc injection(See Page 4)
If the patient is unable to eat and drink after DKA resolution change to Intravenous Variable rate infusion

Pathway of Care for Diabetic Ketoacidosis in Adults ULHT/CESC/2018/048 CESC Approved July 2018 Review July 2021