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1、Treatment Pathway and care guidelines for Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar StateDiagnostic Tool / CriteriaFor diagnostic criteria see Management of Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State (DKA and HHS) guidelines (already submitted). Community treatment and r
2、eferral pathwayFirst aid guidelines for GP, patient will need admission if: Blood sugar greater than 14, despite treatment adjustments Ketones equal to or greater than 2 Any signs and symptoms of DKA / HHS Refer to medical team on call and admit to acute medical admission ward for assessment. First
3、aid guidelines for ambulance crew / paramedics Follow medical emergencies guideline Ensure airway maintained Ensure high flow O2 therapy Obtain IV access, and commence rehydration using sodium chloride intravenous 0.9%, 250mls rapidly (up to 20ml/kg in children) and then reassess vital signs, prefer
4、ably on route to hospital If vital signs and perfusion improve, slow down infusion “to keep vein open” rate If no improvement, give a further 250mls and reassess, repeating process to maximum 2 litres of fluid (40ml/kg in children). Provide hospital alert message / information call and transport to
5、nearest receiving hospital for urgent hospital treatment. Acute DKA and HHS pathwayFollow Management of Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State (DKA and HHS) guidelines (already submitted). For prescription and treatment in ward areas see Guideline for the management of blood sug
6、ars in Hyperglycaemic emergencies in adults with Diabetes (Diabetic ketoacidosis (DKA) and Hyperglycaemic Hyperosmolar State (HHS) (already submitted). In practice this form is colour coded to yellow, ICP should follow this. Discharge procedure Before discharge patient should be seen by Diabetes Spe
7、cialist Nurse for education regarding sick day rules. Follow up appointment with Diabetologist Referral to community DSN for ongoing support and contact advice. Prevention and self management with first aid guidanceTen key points:1. Be prepared, any illness can affect Diabetes and usually increase b
8、lood glucose levels, so even if you are not eating or drinking very much, your blood glucose can rise. Illnesses such as common cold, flu, abscesses, urinary infections, stomach upsets, sore throats or bronchitis, can affect your Diabetes. Always have a supply of monitoring equipment and sugary flui
9、ds / sweets at home.2. Blood glucose often rises, at times of illness, your body is under stress and this usually raises your blood glucose levels. Do test your blood glucose more regularly, every 2 - 4 hours depending on how poorly you are feeling. If you are unable to check ask a friend or relativ
10、e for help. If your blood sugars are above 14 mmol/l, and you take Insulin injections, also check your blood or urine for Ketones. (See point 6.) 3. Never Stop Taking Your Diabetes Medication / Insulin, even if you are not eating or drinking very much. 4. Consider alternative drinks / foods, try to
11、drink plenty of liquids such as water or sugar free squash, especially if your blood glucose is high (hyperglycaemia) sip 3 - 4 litres a day. If your blood glucose is low (hypoglycaemia under 4 mmol/l) drink sugary soft drinks, milk or fruit juices. Aim for one small glass of sugary drink an hour (i
12、f your blood glucose is low) as well as lots of water or sugar free drinks.You maybe unable to eat your usual meals, and will need to have alternative foods that have starch or carbohydrate at regular intervals (every 2 - 3 hours) if your blood glucose is lower you may need to have it more often. Th
13、e foods / drinks below all contain 10 grams of Carbohydrate. 200ml thickened/ broth based soup 1 plain yoghurt 1 dried fruit yoghurt 1 scoop of ice cream 3 Glucose tablets 1 sachet of Complan 50mls of Lucozade 100mls natural fruit juice 100mls of Cola, Lemonade or other full sugared fizzy drink (def
14、izzed is easier to sip) 200ml of milk5. Tell a friend or relative, if you are on your own, that you are ill, and ask them to check on you every 4 - 6 hours.6. Test for ketones, if you have insulin injections, and your blood sugars rise above 14 mmol/l or you are feeling nauseous, have been sick or h
15、ave abdominal discomfort test your urine or blood for ketones.Ketones are a sign that your body is lacking insulin, and requires larger insulin doses. If ketones persist or increase in quantity, you can become unwell due to your diabetes. Do not exercise if ketones are present.Ketone levelActions re
16、quiredKetone levels of 1 or under in blood or urine An acceptable reading, and a sign that your body is breaking down fat to provide your fuel.Ketone level of 1-2 in your blood or urine An elevated reading and a sign that extra insulin is required Test blood glucose and ketone (urine or blood) every
17、 2 hours Contact your GP or Diabetes centre for ongoing adviceKetone level of 2 -3 in your urine or Blood This is a sign of serious diabetes illness (Diabetic Ketoacidosis) You should contact your GP or attend A&E for immediate help and medical treatment.7. Consider Having More Insulin. When your bl
18、ood glucose is above 14 mmol/l for more than 2 readings and urine or blood ketones are present. Increase all future insulin doses by 1/5 Continue to test blood glucose 1-2 hourly and urine or blood ketones every 2 hours.Blood glucose above 20 mmol/l or higher / and / or urine or blood ketones presen
19、t This requires immediate treatment If you use a clear quick acting, analogue insulin (Novorapid, Humalog Lispro, Actrapid, Humulin S) take 8 units as an extra dose. If you have a twice a day insulin regime (Novomix 30, Humalog Mix 25 , Humalog Mix 50 or Human Mixtard 10, 20, 30, 40, 50 or Humulin M
20、3 , M5) take 1/5 of usual insulin (or 10 units if usual dose above 50 units) now as extra dose. Continue to test your blood glucose every 1-2 hours and urine or blood ketones every 2 hours and discuss making further increases with your GP or Diabetes Specialist Nurse.8. Contact your GP or Diabetes S
21、pecialist Nurse for support when: Vomiting or diarrhoea for more than 6 hours Unable to eat or drink for 4 hours Your illness has not improved after 2 days You have had high blood glucose levels (above 14 mmol/l) for 24 - 48 hours with or without urinary or blood ketones.9. Seek urgent medical advic
22、e from your GP, Diabetes Specialist Nurse or Accident and Emergency Department if the signs of Diabetes Ketoacidosis (dangerously high blood glucose and ketones) present, such as: Stomach pain Nausea or vomiting Rapid breathing or heart beat Fruity breath ketone breathe Thirst or passing urine often
23、 Weakness or tiredness Visual changes / problems Sleepiness / problems staying awake 10. Continue to monitor blood glucose regularly, when recovered from illness, blood glucose levels should settle and insulin injections will probably need reducing again. Contact your GP, Diabetes Specialist Nurse for advice.