Management of Diabetic Ketoacidosis (DKA)

Diabetic ketoacidosis, commonly known as DKA, refers to a serious complication that occurs in people suffering from diabetes mellitus. For centuries before insulin therapy was developed in 1920s, DKA was considerably fatal. The occurrence of DKA across the globe varies with the awareness, attitudes and knowledge on diabetes care and management. In developed countries, the occurrence of DKA is relatively; for instance, in the United Kingdom, approximately 4% of type 1 diabetes patients are affected by DKA annually. This rate is relatively higher in other countries where the management of such disease is not fully appreciated; an example is Malaysia where DKA affects 25% of the people with type 1 diabetes. Although statistics may show DKA as a condition that only affects a small percentage of the general population, it is relatively fatal if proper management is not timely provided. 

Diabetic ketoacidosis mostly occurs in type 1 diabetes though it can also be diagnosed in patients with other types of diabetes in special circumstances. The causes of DKA include wrong dosage of insulin, infection, stroke and specific medications such as steroids. These causes lead to insulin irregularities in the blood. Diabetic ketoacidosis is a consequent of insulin shortage in the blood. Reduction in insulin in the blood means that glucose will not be broken down to produce energy. As a result, the body is prompted to break down fatty acids to release energy. When fatty acids are broken down to produce energy, ketone bodies are released. These ketones are acidic hence the condition diabetic ketoacidosis. Typically, DKA is diagnosed when low blood pH, elevated blood sugar and ketoacidosis are found during testing. These factors can be diagnosed in blood or urine (Kitabchi, et al., 2013). 

DKA presents the following signs and symptoms when it occurs: abdominal pain, vomiting, frequent urination, deep wheezing when breathing, confusion, weakness and in some instances the person may lose consciousness. When diabetic ketoacidosis occurs, the patient’s breathe changes and has a specific fruity scent that is often compared to that of pear drops. Patients with diabetic ketoacidosis experience austere dehydration thereby requiring intravenous fluids to balance the bodily fluids. Ketoacidosis occurs rapidly and the patient may not realize what is happening until it is too late. People who have not been diagnosed with diabetes yet are most likely to suffer from DKA. This is because they have not learnt to balance their blood sugars yet. In patients where DKA was caused by an underlying disease, it is imperative to treat the patients with antibiotics so as to treat the causation. DKA patients whose blood pH is severely low are given a specific amount of sodium carbonate. However, this practice is of unknown benefit to the patient and therefore it is characteristically not recommended by health professionals (Misran and Oliver, 2015). 

As stated earlier, DKA is fatal if its management is not provided timely and adequately. Currently, the risk of fatality from DKA is approximately 1- 4% across the globe. The chances of survival are tremendously increased if proper care is provided and in a timely manner. One major common and most dangerous complication of diabetic ketoacidosis is cerebral edema which refers to the swelling of the tissues of the brain. Cerebral edema is most commonly diagnosed in small children and young adult and quite rare among adults. Cerebral edema manifests with severe headaches and may lead to comas. As it progresses, swelling of the brain tissues causes the loss of the light reflex of the pupillary and consequently may lead to death. Statistics show that cerebral edema arising from DKA has a 20 to 50 percent mortality rate (Brown, 2014). This implies that it is imperative for DKA to be managed adequately and timely to avoid complications and fatality. 

PICO Table 

PICO table	Example:
P (patient/problem)	Diabetic ketoacidosis
I (intervention/indicator)	Bolus dose of Insulin injection
C (comparison)	Fluid stabilization first before the insulin injection is administered. Saline administration as well as addition of potassium to the intravenous fluids
O (outcome)	Shock is avoided and irregularities in hear rate are reduced when fluids and potassium are regulated before insulin is administered.

PICO question; ‘Is fluid stabilization a better intervention in the management of diabetic ketoacidosis than insulin injection?’ 

Key words: diabetic ketoacidosis, hypokalemia, insulin, ketone bodies, fluid replacement and cerebral edema 

Research Strategy 

Researching the medical topic diabetic ketoacidosis provides numerous articles that can be used in the study. These articles include peer- reviewed journal articles and other non- research sources. Though most of the research conducted on the topic was done in the 2000s, several, though not many, articles were still written in the 2010s. Online article that are concerned with diabetes are countless and in this document several of the articles have been used. Similarly, government and health websites have provided significant insight into the topic. 

An article by Shara Bialo, Sungeeta Agrawal, Charlotte Boney and Jose Quintos in the World Journal of Diabetes provides information on the rare complications that arise in children with DKA. The article states that over a third of the pediatric patients suffering from type 1 diabetes have at some point presented with DKA thus making DKA one of the leading causes of death among the pediatric population (Bialo et al., 2015). According to another article in the Diabetes care journal presented by the American diabetes association, diabetic ketoacidosis accounts for more than half a million hospital das every year thus translating to 2.4 billion dollars in terms of hospital expenses and other indirect costs. This article points out other complication that may occur even when ketoacidosis is not at an alarming rate such as hyper- osmolality, hyperglycemia and dehydration. The article states that although autoimmune diabetes patients are at higher risks of suffering from DKA, patients with Type 2 diabetes can also get the complication. In most cases, people with Type 2 diabetes suffer DKA when they are in catabolic stress fir to acute illnesses like infections, surgery and trauma (Kitabchi, 2013). 

The National Institute for Health and Care Excellence (NICE) has a website that is updated regularly to provide guidelines that are helpful in the diagnosis and management of several diseases. In the diabetes webpage that was last updated in July 2016, NICE provides guidelines in the diagnosis as well as the management of type 1 diabetes among the adult population aged 18 and above. In this latest update, the website has provided clarification for the roles of GPs in the reference for people for screening of the eyes and has also stipulated when the referencing should. In addition to this, the webpage has provided section that the reader can use to find more information on insulin therapy, diagnosis of diabetes, management of blood glucose concentration, how to manage complications that arise from diabetes and finally raised awareness for hypoglycemia (NICE, 2016). 

The national diabetes association in the United Kingdom provides a website where they keep interested readers informed about the condition. In a 2017 update, the website provides significant information about diabetes so as to help in the fight against the disease. The update explains how continuous high blood glucose levels leads to diabetic ketoacidosis. This occurs when insulin deficiency is severe hence the body cannot breakdown glucose to produce energy. As a result, fatty acids are used as an alternative source of energy for the body. A by- product of fatty acid breakdown is ketone bodies which are poisonous chemicals. When the ketones buildup, their acidity becomes poisonous (Diabetes UK, 2017). 

Evidence Matrix 

Authors	Journal Name	Year	Re-search Design	Sample Size	Outcome Variables Measured	Level	Quality	Results/Author’s Suggested Conclusions
Andrade, Colunga, Delgado. Gonzalez,	The Cochrane database of systematic review	2016	Quantitative study (randomized trials)	201 participants	Insulin administered subcutaneously and regular intravenous insulin	I	B	There is low to very low quality evidence that provide insight to the drawbacks and strengths of using insulin that acts rapidly administered subcutaneously and the regular acting insulin that is provided intravenously in the treatment of moderate DKA.
Brown T. B.	Emergency medical journal	2014	Qualitative study (reviewing primary articles)	29 scholarly articles	The study is set to find out if treatment of diabetic ketoacidosis causes cerebral edema in children	2	c	The study concluded that the claim that treatment of diabetic ketoacidosis causes cerebral edema in children is unsubstantiated
Lawrence J. M. et al.	Diabetes care journal	2014	Quantitative study (statistical analysis)	Registered youths from five states	Statistics were analyzed to find out the incidence of type 1 diabetes among non- Hispanic white youth	1	A	The incidence of type 1 diabetes has generally increased among NHW youths
Seth, P.  Kaur, H.  Kaur, M.	Journal of clinical and diagnostic research	2015	Prospective study	60 diabetic patients	Finding out the clinical profiles, clinical outcome and precipitating factors in the DKA patients visiting emergency tertiary care	2	A	DKA is an acute complication of type 1 diabetes that presents heterogeneous clinical presentations. If diagnosis and treatment occurs timely then morbidity and mortality can be avoided.
Couch R., et al.	Agency for Healthcare Research and Quality	2014	Quantitative study	80 studies were used	The study is set to find out how effective diabetes education is in the control of metabolism.  Furthermore, it is to find the level of knowledge and complications of diabetes and how it affects hospitalizations	1	A	The study did not find any sufficient confirmation to state that a certain intervention is more effective than the typical standard care of diabetes.

Recommended Practice Change 

Currently, diabetic ketoacidosis is primarily managed using insulin to balance the blood sugars and intravenous fluids to stabilize the bodily fluids. The administration of insulin can occur intravenously or using an under the skin injection depending on the severity of the condition. Patients with DKA are typically treated with a dose of insulin. Certain health professionals and researchers recommend giving a DKA patient a large dosage of insulin on admission that is 0.1unit/kg body weight. However, it is vital to confirm that potassium levels are safe, that is potassium levels are greater than 3.3mmol/l. if potassium levels are lower than this, insulin administration will reduce them even further thus creating more complications for the patient (Andrade, 2016). 

However, some guidelines have pointed out that fluid replacement should first occur and ensure that electrolytes especially potassium are balanced before insulin injection. Fluid replacement depends on the extent of dehydration. In severe cases such as in instances of cardiogenic shock, the patient is required to be put in an intensive care unit for observation of the central nervous system and provision of medication to increase the pumping action of the heart (Lawrence, 2014). Some researchers have taken this factor in consideration and have recommended that insulin administration should be delayed until bodily fluids and salts have stabilized to avoid shock. This implies first administering the fluids to stabilize the patients then providing the insulin. In such instances, fast acting insulin is administered by injections under the skin. Basically, 0.1unit/kg per hour is the rate that insulin is administered to the patient until blood sugars have reduced and ketone production has ceased (Seth, Kaur, and Kaur, 2015). 

Bodily fluids replacements occur during dehydration. In cases whereby the dehydration was so high such that it caused shock, then a rapid of saline is recommended. Shock in dehydration refers to a condition whereby the blood pressure has severely dropped thus inhibiting oxygen circulation into the body organs. Similarly, rapid infusion of saline is given to patients who have a low level of consciousness. When dehydration is moderate, saline is provided after water and sodium circulation levels in the body are determined. In instances whereby a DKA patient has mild dehydration without vomiting, then dehydration is done subcutaneously and orally rather than intravenously. However, the patient is kept under observation to avoid any signs of symptom deterioration (Brown, 2014). 

An important aspect in the management of DKA is the management of potassium levels in the blood. During treatment of DKA, blood potassium and blood sugars are closely monitored to avoid any further complications. Hypokalemia refers to depressed blood potassium levels. As much as it occurs in patients with DKA, it is exacerbated by insulin administration. Hypokalemia occurs when huge amounts of potassium, are lost through urine due to osmotic diuresis. Potassium depression in blood causes heart rate irregularities which may worsen if the concentration of potassium is not balanced. Therefore, during management of DKA, potassium levels are closely monitors as well as continuous observation of the heart rate. In situations where potassium levels are low, 5.3mmmol/l of potassium is added to the intravenous fluids that are being administered to the patient. In cases where potassium levels are below 3.3mmmol/l, insulin administration is halted till potassium levels stabilize (Couch R., 2014 ). 

Recommended Practice Change 

The intervention of stabilizing fluid and electrolyte concentration in blood before insulin injection in diabetic ketoacidosis involves three key stakeholders that is the physician, the nurse and the patient. A seminar can be held in hospitals to inform health professionals about the importance of first balancing fluids and electrolytes in DKA patients. This can be done in turns to ensure maximum coverage. Consequently, the health professional will be expected to teach the patient how the treatment is done just in case they find themselves in similar situations; furthermore, the patient has to be informed on the treatment they are receiving. 

A major barrier that may be experienced during the adoption of this system of intervention is time. People with DKA deteriorate and barely have time for tests to be done. In such instances, health professionals may be tempted to start on the insulin injection immediately a diabetic patient comes into the hospital without finding out the concentration of potassium and this may worsen the situation. Another barrier is changing what people are used to. Health practitioners are used to providing insulin injections to diabetic patients when their blood sugars fluctuate. It will be difficult for them to adjust to the new setting that they have to check the electrolyte levels first rather than checking the blood glucose levels. 

These barriers can best be overcome with patience. Healthcare practitioners will have to understand that instead of quickly jumping to an insulin injection, it is wise to take a few minutes and test the electrolyte concentration of the patient before any intervention. This will best determine which step to be taken next thus increasing the chances of patient survival and reduces any risks of complications. Furthermore, rigorous training will help in providing more information to the health professionals on the importance of fluid replacement before insulin injection. 

Outcomes of this practice change can be found in the statistics on mortality and morbidity in DKA patients. Currently, statistics are available to show how many people suffer from DKA and what the mortality rate is from the complication. After the intervention, the statistics of fatality as well as morbidity can be used to indicate whether the intervention worked or not. 

References

Andrade C. A., Colunga, L. E., Delgado F. N. and Gonzalez P. D. (2016). Subcutaneous Rapid Acting Insulin Analogues for Diabetic Ketoacidosis. The Cochrane Database of Systematic Reviews 1 (1): 1281- 1292 

Brown T. B. (2014). Cerebral Edema In Childhood Diabetic Ketoacidosis: Is Treatment A Factor? Emergency Medical Journal , 21 (2): 141- 144 

Couch R, Jetha M, Dryden D. M, Hooton N, Liang Y, Durec T, Sumamo E, Spooner C, Milne A, O’Gorman K, Klassen TP. (2014). Diabetes Education for Children with Type 1 Diabetes Mellitus and Their Families. Agency for Healthcare Research and Quality, 166 (8): 1- 282 

Diabetes UK. (2017). Diabetic ketoacidosis (DKA). Retrieved on June 15, 2017 from https://www.diabetes.org.uk/guide-to-diabetes/complications/diabetic-ketoacidosis/ 

Edge, j., (2009). BSPED Recommended DKA Guidelines 2009. British Society for Pediatric Endocrinology and Diabetes . Print 

Kitabchi A. E.; Umpierrez G. E.; Miles J. M. and Fisher J. N., (2013). Hyperglycemic Crises in Adult Patients with Diabetes. Diabetes Care 32 (7): 1335- 1343 

Misran, S. and Oliver, N. S. (2015). Diabetic Ketoacidosis in Adults. British Medical Journal; Clinical Research Edition , 351: 5660 

Silverstein J., Klingensmith G., and Copeland K., (2015. Care of Children and Adolescents with Type 1diabetes: A Statement of the American Diabetes Association. Diabetes Care 28 (1): 186- 212 

The National Institute for Health and Care Excellence. (2016). Type 1 diabetes in adults: diagnosis and management. Retrieved on June 15, 2017 from www.nice.org/uk/guidance/ng17/chapter/1-recommendations#insulin-therapy-2