An audit of the management of diabetic ketoacidosis at St Luke’s Hospital

Aim: To perform an audit of the protocol used in the management of patients with Diabetic Ketoacidosis, in St Lukes Hospital. Methods: Patients admitted with ‘Diabetes Ketoacidosis’, between 14 August 2004 and 14 August 2005, were identified from the Admission book at the Accident and Emergency Department. Data obtained from patients’ medical records were collected according to a preset proforma. The criteria assessed by this audit included parameter monitoring, investigations performed, the type and amount of intravenous fluids given, the insulin regime and potassium supplements used. Results: From a total of fifty six patients, forty seven files were traced, of which seventeen satisfied the criteria for Diabetic Ketoacidosis. Two were excluded and fifteen were analysed. In the population studied the mean age was 28 years with a male predominance of 60%. Ten patients suffered from Type 1 Diabetes whilst two patients had Type 2 Diabetes. Three other patients were newly diagnosed. Only one patient had all parameters checked according to protocol. In the majority of patients, fluids given in the first 22 hours, coincided with the amount of fluids stated in the protocol whilst 6/15 (40%) patients were administered the requested amount of insulin via infusion pump. With regards to potassium replacement, 13/15 (87%) patients were started on potassium supplements at a later stage. The factors influencing the total time for conversion to a fixed insulin regime and the duration of stay in hospital were also analysed. Conclusion: Deviations from the protocol were identified in parameter recording, the type of intravenous fluids given and the doses of insulin and potassium supplementation administered. New Diabetic Ketoacidosis guidelines have now been developed. Introduction Diabetic Ketoacidosis (DKA) is a state of uncontrolled catabolism associated with insulin deficiency, counterregulatory hormone excess and fluid depletion. It is the hallmark of Type 1 Diabetes (DM) and can be its mode of presentation. However, patients with Type 2 DM are also at risk of developing DKA during the catabolic stress of acute illness. Signs and symptoms of DKA include polyuria, polydipsia, lethargy, anorexia, hyperventilation, ketotic breath, dehydration, vomiting, abdominal pain and coma. Precipitants include infections, psychological stress, poor compliance with therapy, cerebrovascular accidents, alcohol/drug abuse, pancreatitis, pulmonary embolism, myocardial infarction, trauma and drugs. DKA continues to be an important cause of morbidity and mortality amongst patients with diabetes. Mortality rates in DKA, quoted at <5%, increase substantially with increasing age and concomitant life-threatening illnesses. DKA treatment outcomes are similar in both community and teaching hospitals, and do not vary with the level of expertise of the managing physician, so long as standard written therapeutic guidelines are followed.