1. Reducing Risks:. A New Protocol for the Fluid Management
Reducing Risks: A New Protocol for the Fluid Management of Paediatric Diabetic Ketoacidosis (DKA)
Jacqueline Wilkinson
Aseptic Services Pharmacist
Wrexham Maelor Hospital

2. Aims of presentation Explain Background New protocol
Problems identified that prompted us to review practice
New protocol
How it works
Benefits to patients
Risk reduction
Reducing delays in treatment
More optimised provision of rehydration fluid

3. Summary of problem DKA is a medical emergency
Management of paediatric DKA is complex, involving several infusions of varying concentrations of glucose and saline, plus potassium and insulin.
Requirements are determined by a multistage calculation process and change rapidly, in line with a fast changing biochemical picture.
Speed is essential
Risks of delay and error are high.

4. Resuscitation (normal saline) Insulin Rehydration
Treatment aims
Resuscitation (normal saline)
Given immediately on admission
Insulin
(continuous intravenous infusion)
Rehydration
Replace volume and electrolytes
Here is where difficulties encountered in obtaining required fluids
Focus of protocol

5. Fluid volumes- rehydration fluid
Accurate calculation of fluid requirements important in children
Over zealous rehydration risks cerebral oedema
Rehydrate over a 48 hour period
This amount is calculated at admission
Complex multistage calculations which take into consideration:
Body weight
Maintenance fluid appropriate for weight
State of hydration
This is estimated and quantified by assessment of clinical features when the patient is admitted
Minus the resuscitation fluid
Components of the fluid are decided by other factors
Biochemistry
Volume per hour remains the same over the 48 hour period
COMPONENTS CHANGE IN RESPONSE TO CLINICAL PICTURE
3 hourly bloods

6. Problems Rehydration fluid required often not available commercially
Particular problem with potassium containing fluids
Prepared either
on an adhoc basis in our aseptic unit during working hours when capacity available
urgent, unpredictable requests for various formulations or
on the ward out of hours

7. 2. Delays in treatment incurred due to
Preparation of potassium containing fluids on wards associated with two main problems:
1. Risk
(Subject of NPSA guidance)
Avoidance of use of conc. KCl ampoules
Avoidance of preparation of IV infusions of wards
Calculation/contamination risks
2. Delays in treatment incurred due to
Difficulty with availability/ sourcing required fluids within time restraints
Rapidly changing requirements
Bloods done three hourly initially

8. Problems Can we resolve the problem by increasing the stock?
Range of potentially required fluids to meet all needs was vast
Potassium
Some evidence to suggest prescribing/guidance often suboptimal
Based on what was available commercially rather than what was required clinically.

9. Rationalisation

10. Aims of protocol (4)
1. To optimise adherence to current NPSA guidance and best-evidenced DKA practice
2. To formulate a range of infusions which would remove the need to prepare any product on the ward and therefore reduce risks associated with the practice

11. Aims (continued)
3. To facilitate easy, minimum-risk prescribing
4. To facilitate variation within defined limits of
fluid volume
glucose concentration
electrolytes
Insulin
which could be administered to the whole spectrum of paediatric patients, using the minimum of infusion container changes

12. Method We conceived a new approach
Co-administration of an in-house pharmacy prepared potassium infusion, together with the appropriate crystalloid infusion.
Each infusion would be independent and the rate of each could be varied to achieve a very wide range of concentrations of glucose and electrolytes.
Potassium- standard concentration, variable rate
(within limits)
Crystalloid- variable concentrations, variable rates
We also designed support documentation
A series of tables
Prescription chart specific to the protocol

13. The new protocol
500ml bags of crystalloid to be infused at variable rates dependent upon weight and state of dehydration
Available as stock will be:
Sodium chloride 0.9% ml
Sodium chloride 0.9% / glucose 5% ml
Sodium chloride 0.9% / glucose 10% ml
Sodium chloride 0.45% / glucose 5% ml
Sodium chloride 0.45% / glucose 10% ml
Pre-filled syringes of potassium chloride 0.4mmol/ml to be infused at either
0.15mmol/kg per hour or
0.25mmol/kg/hour
0.3mmol/kg/hour
Soluble Insulin in prefilled syringes
50units in 50ml

14. Nominated locked fridge on HDU on childrens ward
Restricted access
May only be used for patients with PDKA

15. Benefits
Reduces potential for error and delays by eliminating need to make up infusion on ward.
1. Reduces delays in treatment
(by reducing delays encountered by difficulties obtaining stock e.g., from ITU or from on call pharmacist).
2. Enables wide ranging flexibility from a small range of easily stocked products
3. Provides user friendly standardised calculation algorithm
4. Enables standardised prescribing

16. Example
Column A
Initial Rehydration with moderate potassium supplementation
0.15mmol/kg/hour
Potassium chloride pre-filled syringe 0.4mmol/ ml
Crystalloid hydration fluid ml/hour 1 2 3 4 5 Wt
(kg)
ml/hour
3% dehydrated
5% dehydrated
7.5% dehydrated
10% dehydrated 22
8.3
60.5
69.7
81.1
92.6 24
9.0
61.8
71.8
84.3
96.8 26
9.8
63.2
74.0
87.5
101.1 28
10.5
64.5
76.2
90.8
105.3

17. Risk Management: Potassium prescribing and administration
Potassium must be co-infused with crystalloid.
Serious error if directly infused into patient
Maximum of 10mmol per syringe
To avoid gross over infusion
Prescribing
Use pre-printed prescription
Doctor may only prescribe 3 hours worth of potassium at a time
After this time, nurses may not continue to infuse potassium if it is not prescribed
Serum potassium must be recorded

18. Training Nurses Doctors Pharmacists Protocol developed with
Consultants/registrars
Charge nurse
Paediatric pharmacists

19. Results
The writing of the protocol, development of supporting products and training of relevant staff was completed in February 2007 and was first used in March 2007
Used in a small number of patients
Next stage  Audit
Incorporation with ICP

20. Conclusion
We believe that the development of this new protocol has improved our management of paediatric patients who are admitted with DKA by:
Reducing risks associated with calculation errors and ward preparation of potassium infusions
Entirely eliminating delays in sourcing required infusions
Providing a standardised yet very flexible, straight forward protocol for their management

21. Thank you
Any questions?