Management of diabetic ketoacidosis following implementation of the JBDS guidelines: Where are we and where should we go?

Background: The Joint British Diabetes Society (JBDS) consensus guideline published in 2010 has provided the framework for the effective management of diabetic ketoacidosis (DKA) in adults in the UK. Methodology: A retrospective study of 50 patient episodes admitted to our teaching hospital between February and December 2012, with a discharge diagnosis of DKA. Results: Twenty-seven (54%) patients were male, mean (SD) age was 43 (21) years and duration of diabetes was 11 (9) years. In the first 60 minutes from diagnosis, median (interquartile range [IQR]) time to fixed rate intravenous insulin infusion (FRIII) was 49 (29-110) minutes and to intravenous fluids was 19 (0-42) minutes. During ongoing management, 46% of patients developed hypokalaemia and, of those, in 70% potassium supplementation was not prescribed as per protocol. Forty percent of patients experienced hypoglycaemia in the first 24 hours, of whom 80% had 10% dextrose prescribed appropriately according to protocol. Median time to hypoglycaemia from diagnosis was 12 hours 54 minutes. Median (SD) time to resolution of DKA was 12 hours 6 minutes. Eighty six percent of patients were reviewed by the diabetes specialist team during admission. No deaths due to DKA or complications of its management were reported. Median length of hospital stay was two days. Conclusions: Adherence to the JBDS DKA guideline was good in the immediate stage of treatment. Inadequate metabolic monitoring, fluid management and iatrogenic hypoglycaemia remain areas of concern. A high proportion of patients received diabetes specialist nurse input with reduced length of stay and no recorded mortality. Our recommendations as a result of this audit include a strengthened programme of teaching and education for nursing and medical staff, focus on metabolic monitoring and improved patient contact after hospital discharge.