Endocrine Abstracts

Since the introduction of national BSPED DKA guidelines we wondered whether the previous variability in DKA guidelines would be abolished.

Aim: To explore the variability of guidelines in three regional diabetes networks in South West (SW) and South Central England and to compare them to the current BSPED guidelines.

Methods: Within an audit of in-patient care, a copy of the DKA guidelines was requested from 27 services. General layout, fluid and insulin, potassium and bicarbonate recommendations and cerebral oedema (CO) management were analysed.

Results: Thirteen guidelines were obtained from 20 centres (seven centres in SW use the same integrated care pathway). Three were between 5 and 7 years out-of-date. For shock, all suggested 0.9% NaCl, with an initial 10 ml/kg fluid bolus in 10 guidelines and a maximum 30 ml/kg in nine. All stated a maximum degree of dehydration; one used 7.5%, five used 8% (new BSPED maximum), and seven used 10%. The rehydration period varied; 48 h in 11, 24–36 h in one and 36 h in one. A standard calculation was done of a 6-year-old child weighing 20 kg, maximally dehydrated; the variation in initial fluid replacement was substantial, between 75 and 137 ml/h. 0.9% NaCl with KCl was continued for 12 h in five guidelines. Eight suggested delaying insulin for an hour after IV fluids. Insulin infusion rate started at 0.1 units/kg per h in 11 guidelines. Five guidelines clearly instructed maintaining the insulin infusion rate when BG fell to 14 mmol/l. CO was mentioned as an important cause of morbidity in all guidelines. All suggested either mannitol or hypertonic saline and to reduce fluid rate to 2/3 or 1/2 maintenance rate.

Conclusion: In spite of availability of national and international guidelines, a large degree of variation still exists in many aspects of management. In particular, variation in fluid calculations remains a concern, given that fluid volume is a risk factor for CO.