Diabetic Ketoacidosis Clinical Pathway

Pathway Background and Objectives

Diabetic Ketoacidosis (DKA) is a potentially fatal metabolic complication of uncontrolled diabetes mellitus. DKA consists of the biochemical triad of hyperglycemia, ketonemia and metabolic acidosis, resulting from absolute or relative insulin deficiency in the presence of an increase in counter regulatory hormones. Evolving treatment for diabetic ketoacidosis in specialized centers retains three basic elements: meticulous monitoring of vital signs and biochemical responses, provision of intravenous insulin, and replacement of fluids and electrolytes. Over the years, remarkable improvement has been made in the prognosis of DKA, due to clinical guidelines and well-constructed management protocols. This pathway aims to establish a clear, unambiguous written protocol, adapted to our local circumstances for appropriate triage and management of DKA. The objectives of this pathway are to:

Decrease variation in care for patients with DKA
Establish evidence-based care standards that are delivered in a timely manner
Monitor and improve outcomes for patients with DKA

Algorithm

Educational Module

Download DKA Educational Module

Quality Metrics

% of patients with pathway order set usage
% of patients on DKA pathway ≤24 hours (excluding patients with pH <7.0)
% of patients without hypoglycemia while on pathway
% of patients with 1-2 episodes of hypoglycemia after pathway completed
% of patients with 3 or more episodes of hypoglycemia after pathway completed
% patients with documented reason for DKA (exclude new onset DM)
% patients with follow up appointment scheduled at discharge
Average length of stay (days) excluding patients with pH <7.0

Key References

Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WR, Rosenbloom A, Sperling MA, Hanas R; International Society for Pediatric and Adolescent Diabetes. Diabetic ketoacidosis. Pediatr Diabetes. 2007 Feb:8(1):28–43.
Cooke DW, Plotnick L. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5.
Wolfsdorf J, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State: A Consensus Statement from the International Society for Pediatric and Adolescent Diabetes. Pediatr Diabetes. 2018 Oct; Suppl 27:155-177.
Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism. 2016 Apr;65(4):507-21.

Disclaimer

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.