Evidence-based management of hyperglycemic emergencies in diabetes mellitus

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

BACKGROUND

Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used.

METHODS

We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip.

RESULTS

Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001).

CONCLUSIONS

In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.

Hypernatremia in Hyperglycemia: Clinical Features and Relationship to Fractional Changes in Body Water and Monovalent Cations during Its Development

In hyperglycemia, the serum sodium concentration ([Na]S) receives influences from (a) the fluid exit from the intracellular compartment and thirst, which cause [Na]S decreases; (b) osmotic diuresis with sums of the urinary sodium plus potassium concentration lower than the baseline euglycemic [Na]S, which results in a [Na]S increase; and (c), in some cases, gains or losses of fluid, sodium, and potassium through the gastrointestinal tract, the respiratory tract, and the skin. Hyperglycemic patients with hypernatremia have large deficits of body water and usually hypovolemia and develop severe clinical manifestations and significant mortality. To assist with the correction of both the severe dehydration and the hypovolemia, we developed formulas computing the fractional losses of the body water and monovalent cations in hyperglycemia. The formulas estimate varying losses between patients with the same serum glucose concentration ([Glu]S) and [Na]S but with different sums of monovalent cation concentrations in the lost fluids. Among subjects with the same [Glu]S and [Na]S, those with higher monovalent cation concentrations in the fluids lost have higher fractional losses of body water. The sum of the monovalent cation concentrations in the lost fluids should be considered when computing the volume and composition of the fluid replacement for hyperglycemic syndromes.

Diabetic Ketoacidosis Management: Updates and Challenges for Specific Patient Population

Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death that could be prevented in patients with diabetes mellitus. DKA occurs more commonly among patients with type-1 diabetes with a thirty percent of the cases take place in patients with type 2 diabetes. DKA is characterized by sever hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive replacement and monitoring of fluids, electrolytes and insulin therapy. Management of DKA has been updated with guidelines, to help standardize care, and reduce mortality and morbidity. The major precipitating factors for DKA include new diagnosis of diabetes, non-adherence to insulin therapy as well as infection in patients with diabetes. Discharge plans should include appropriate selection of insulin dosing and regimens as well as patient education to prevent recurrence of DKA. Further, definition and management of euglycemic DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors are discussed. Special consideration is reviewed for specific patient population including pregnancy, renal replacement, acute pancreatitis, and insulin pump users as well as patients with COVID-19.

Treatment Considerations and Pharmacist Collaborative Care in Diabetic Ketoacidosis Management

Diabetic ketoacidosis (DKA) is a medical emergency caused by the lack of insulin. Metabolic acidosis, hyperglycemia, and ketoacidosis are its defining features. Insulin deficiency can cause DKA either in the presence or absence of a triggering event causing a chain of pathophysiological changes. Normalizing volume status, hyperglycemia, electrolytes, and ketoacidosis are the objectives of DKA treatment. While hospital pharmacists are involved in managing DKA, community or ambulatory care pharmacists can help to prevent DKA. Depending on the particular field of practice, a pharmacist’s engagement in DKA may involve a number of factors. Inpatient pharmacists are in a good position to help with the acute care of DKA. Because they can recognize patients who are at risk for DKA due to factors including medication nonadherence or insulin pump failure, pharmacists in the community or ambulatory-care environment play a crucial role in its prevention. When a patient finds it challenging to navigate prescription plan coverage or a lack of coverage, community pharmacists can help them obtain insulin. Regardless of the professional environment, patient education is essential. Every pharmacist has the ability to give DKA patients thorough medication education that emphasizes the value of adhering to their drug schedule, addresses any obstacles that may occur, and teaches patients how to correctly monitor their blood glucose levels. Studies showed that pharmacists’ medication counseling and treatment monitoring could improve adherence to insulin medication. The aim of this review is to provide evidence that pharmacists can contribute to optimizing medication adherence and decrease the incidence of DKA.

Fluid Stewardship of Maintenance Intravenous Fluids

Despite the frequent use of maintenance intravenous fluids (mIVF) in critically ill patients, limited guidance is available. Notably, fluid overload secondary to mIVF mismanagement is associated with significant adverse patient outcomes. The Four Rights (right drug, right dose, right duration, right patient) construct of fluid stewardship has been proposed for the safe evaluation and use of fluids. The purpose of this evidence-based review is to offer practical insights for the clinician regarding mIVF selection, dosing, and duration in line with the Four Rights of Fluid Stewardship.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.

Hospitalizations and inpatient mortality for hyperosmolar hyperglycemic state over a decade

OBJECTIVES

This study aimed to describe rates and trends in hospitalizations, inpatient mortality, total hospital charges, and mean lengths of stay among adult patients hospitalized for hyperosmolar hyperglycemic state (HHS).

METHODS

The study included NIS databases 2008, 2010, 2012, 2014, 2016, and 2018. These databases were searched for hospitalizations with a principal discharge diagnosis of HHS in patients with T2DM using ICD codes (25020, 25022, and E110). Patients less than 18 years, elective hospitalizations, HHS in patients with T1DM or secondary diabetes mellitus were excluded. We used multivariable regression analysis to obtain trends in mortality, length of stay (LOS), and total hospital charges (THC).

RESULTS

Between 2008 and 2018, there was a trend towards increasing hospitalizations for T2DM with HHS (p trend < 0.001). The mean age over the period ranged from 56.9 to 59.1 years old. Men made up the majority of hospitalizations. Over the decade, there was a steady rise in the proportion of Whites and Hispanics with HHS, and Medicare was the most prevalent insurer overall. Inpatient mortality for HHS decreased from 1.44% in 2008 to 0.77% in 2018 (p trend 0.007). There was also a statistically significant decrease in both LOS and THC over the studied period.

CONCLUSIONS

Trends in HHS showed increased hospitalizations, LOS, and THC over the decade in the study period, but inpatient mortality declined.

Clinical Characteristics Associated with the Development of Diabetic Ketoacidosis in Patients with Type 2 Diabetes

Objective This study analyzed the clinical and laboratory parameters that might influence the clinical outcomes of patients with type 2 diabetes who develop diabetic ketoacidosis (DKA), which has not been well investigated. Methods We reviewed the clinical and laboratory data of 158 patients who were hospitalized due to DKA between January 2006 and June 2019 and compared the data of patients stratified by the type of diabetes. In addition, the patients with type 2 diabetes were subdivided according to age, and their clinical and laboratory findings were evaluated. Results Patients with type 2 diabetes had a longer symptom duration associated with DKA, higher body mass index (BMI), and higher C-peptide levels than those with type 1 diabetes (p<0.05). Among patients with type 2 diabetes, elderly patients (≥65 years old) had a longer duration of diabetes, higher frequency of DKA onset under diabetes treatment, higher effective osmolarity, lower BMI, and lower urinary C-peptide levels than nonelderly patients (<65 years old) (p<0.05). A correlation analysis showed that age was significantly negatively correlated with the index of insulin secretory capacity. Conclusion Patients with DKA and type 2 diabetes had a higher BMI and insulin secretion capacity than those with type 1 diabetes. However, elderly patients with type 2 diabetes, unlike younger patients, were characterized by a lean body, impaired insulin secretion, and more frequent DKA development while undergoing treatment for diabetes.

Early prediction models for prognosis of diabetic ketoacidosis in the emergency department: A protocol for systematic review and meta-analysis

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most serious complications after diabetes poor control, which seriously threatens human life, health, and safety. DKA can rapidly develop within hours or days leading to death. Early evaluation of the prognosis of DKA patients and timely and effective intervention are very important to improve the prognosis of patients. The combination of several variables or characteristics is used to predict the poor prognosis of DKA, which can allocate resources reasonably, which is beneficial to the early classification intervention and clinical treatment of the patients.

METHODS

For the acquisition of required data of eligible prospective/retrospective cohort study or randomized controlled trials (RCTs), we will search for publications from PubMed, Web of science, EMBASE, Cochrane Library, Google scholar, China national knowledge infrastructure (CNKI), Wanfang and China Science and Technology Journal Database (VIP). Two independent reviewers will read the full English text of the articles, screened and selected carefully, removing duplication. Then we evaluate the quality and analyses data by Review Manager (V.5.4). Results data will be pooled and meta-analysis will be conducted if there's 2 eligible studies considered.

RESULTS

This systematic review and meta-analysis will evaluate the value of the prediction models for the prognosis of DKA in the emergency department.

CONCLUSIONS

This systematic review and meta-analysis will provide clinical basis for predicting the prognosis of DKA. It helps us to understand the value of predictive models in evaluating the early prognosis of DKA. The conclusions drawn from this study may be beneficial to patients, clinicians, and health-related policy makers.

STUDY REGISTRATION NUMBER

INPLASY202150023.

Potassium Concentration in Initial Fluid Therapy and In-Hospital Mortality of Patients with Diabetic Ketoacidosis

CONTEXT

Guidelines worldwide recommend potassium replacement of 10 to 40 mmol/L in the initial fluid therapy for patients with diabetic ketoacidosis. However, evidence is lacking as to the association between infused potassium concentration and mortality.

OBJECTIVE

We aimed to determine the association between infused potassium concentration and in-hospital mortality.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified inpatients admitted for treatment of diabetic ketoacidosis from July 2010 to March 2018. Patients with kidney dysfunction or serum potassium abnormalities were excluded. We evaluated the association of the potassium concentration in the total infused solutions in the first 2 days of hospitalization with 28-day in-hospital mortality using multivariable regression analysis with a cubic spline model. We also assessed the association between potassium concentration and occurrence of hyperkalemia.

RESULTS

We identified 14 216 patients with diabetic ketoacidosis and observed 261 deaths. The quartile cut-points for potassium concentration were 7.7, 11.4, and 16.1 mmol/L. Within the range of approximately 10 to 40 mmol/L, potassium concentration was not associated with occurrence of hyperkalemia or death. Lower potassium concentrations were associated with higher 28-day in-hospital mortality; the odds ratio for patients receiving 8 mmol/L was 1.69 (95% CI, 1.03 to 2.78; reference: 20 mmol/L), and the odds ratio increased monotonically as potassium concentration decreased further.

CONCLUSION

Patients receiving potassium replacement at concentrations of 10 to 40 mmol/L had similar in-hospital mortality rates, whereas lower concentrations were associated with higher mortality.

The effect of diabetic ketoacidosis (DKA) and its treatment on clot microstructure: Are they thrombogenic?

BACKGROUND

Diabetic ketoacidosis (DKA) is a medical emergency with a high mortality rate and is associated with severe metabolic acidosis and dehydration. DKA patients have an increased risk of arterial and venous thromboembolism, however little is known about this metabolic derangement in the first 24 hours of admission and to assess its effect on coagulation. We therefore utilised a novel functional marker of clot microstructure (fractal dimension - df) to assess these changes within the first 24 hours.

METHODS

Prospective single centre observational study to demonstrate whether the tendency of blood clot formation differs in DKA patients.

RESULTS

15 DKA patients and 15 healthy matched controls were recruited. Mean df in the healthy control group was 1.74±0.03. An elevated df of 1.78±0.07 was observed in patients with DKA on admission. The mean pH on admission was 7.14±0.13 and the lactate was 3.6±2.0. df changed significantly in response to standard treatment and was significantly reduced to 1.68±0.09 (2-6& h) and to 1.66±0.08 at 24& h (p < 0.01 One-way ANOVA). df also correlated significantly with lactate and pH (Pearson correlation coefficient 0.479 and -0.675 respectively, p < 0.05).

CONCLUSIONS

DKA patients at presentation have a densely organising less permeable thrombogenic clot microstructure as evidenced by high df. These structural changes are due to a combination of dehydration and a profound metabolic acidosis, which was reversed with treatment. These changes were not mirrored in standard clinical markers of thromboge-nicity.

Management of diabetic ketoacidosis in special populations

Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus that can be associated with increased morbidity and mortality, particularly if it is diagnosed late and not treated appropriately. The management of DKA includes careful clinical evaluation, correction of metabolic abnormalities with intravenous fluids, insulin and electrolyte replacement with frequent monitoring of the patients' clinical and laboratory findings and also identification and treatment of the precipitating condition. There are special populations where features, management and outcome may differ from the usual patient with diabetes. Data on management of DKA in such special populations such as chronic kidney disease and pregnancy are sparse and recommendations are based mainly on small case series and expert opinion. Clinicians need to recognize and manage euglycaemic DKA in patients prescribed sodium-glucose cotransporter inhibitors. DKA is particularly a major health concern due to high rates of hospital admissions and mortality in resource-limited settings due to financial constraints, limiting the adequate provision of insulin and access to health care systems, and dysfunctional health systems. We review the challenges of diagnosis and management of DKA in these specific groups and provide recommendations on optimal patient care.

Neurological Complications of Endocrine Emergencies

PURPOSE OF REVIEW

Endocrine disorders are the result of insufficient or excessive hormonal production. The clinical course is long, and the manifestations are nonspecific due to the systemic effect of hormones across many organs and systems including the nervous system. This is a narrative review of the recent evidence of the diagnosis and treatment approach of these medical and neurological emergencies.

RECENT FINDINGS

With the possible exception of diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia, endocrinological emergencies are complex, uncommon yet life-threatening conditions with protean and often nonspecific early clinical signs. They frequently are the first manifestation of the endocrine derangement. The systemic effects of hormones extend to the nervous system and as such, these conditions can present with neurological complications manifested, in most cases, by a diffuse dysfunction of the brain in the form of encephalopathy, delirium, seizures, and coma; or specific and peculiar syndromes such as hemichorea, hemiballism, and epilepsia partialis continua. The severity of these conditions often necessitates management in the intensive care unit requiring substantial supportive care in addition to specific targeted therapy to correct the hormonal metabolic abnormalities while at the same time blocking hormonal activity, in cases of excessive function, or supplementing hormonal deficiencies. Endocrine emergencies and their neurological complications are infrequent. The major challenge for most is early recognition. Their morbidity and mortality are high and their diagnosis requires high index of suspicion. The neurological complication most often improves with the correction of the metabolic derangement and their acuity and severity require admission to the intensive care unit.

[Acute metabolic complications in diabetes]

Over time, diabetes patients are at increased risk for microvascular and macrovascular complications leading to increased morbidity and mortality compared to metabolically healthy people. In addition, acute life-threatening metabolic derangements at first manifestation as well as during the course of the disease may occur, comprising diabetic ketoacidosis, hyperosmolar hyperglycaemic state and hypoglycaemia. Diabetes-related emergencies require fast diagnosis and early treatment initiation as well as close monitoring of vital signs and laboratory parameters. The present article gives an overview on the acute metabolic complications in diabetes, focussing on diagnostic work-up and treatment goals.

Factors affecting in-hospital mortality of diabetic ketoacidosis patients: A retrospective cohort study

AIMS

With advances in the diagnosis and treatment of diabetic ketoacidosis (DKA), its rate of in-hospital mortality has declined. However, the risk factors for in-hospital mortality in patients with DKA remain to be elucidated.

METHODS

Using a Japanese national inpatient database from 01 July 2010 to 31 March 2018, we performed multivariable logistic regression analyses to identify factors associated with in-hospital mortality of DKA patients.

RESULTS

We identified 25,627 DKA patients and 839 (3.3%) in-hospital deaths. Factors associated with increased in-hospital mortality included higher Charlson comorbidity index (≥4) (odds ratio, 3.38; 95% confidence interval, 2.30-4.96; p < 0.001), sepsis (odds ratio, 3.09; 95% confidence interval, 2.38-4.00; p < 0.001), type 2 diabetes mellitus (odds ratio, 2.67; 95% confidence interval, 2.09-3.41; p < 0.001), and obesity (odds ratio, 2.51; 95% confidence interval, 2.05-3.07; p < 0.001). Other factors positively associated with in-hospital mortality included male sex, age ≥ 60 years, consciousness disturbance, lower activities of daily living score at admission, admission requiring ambulance, and admission at non-academic hospital.

CONCLUSIONS

The present findings may help clinicians to identify DKA patients at higher risk of in-hospital mortality.

The importance of hyperosmolarity in diabetic ketoacidosis

AIM

Diabetic ketoacidosis is a hyperglycaemic emergency that is often treated in intensive care units (ICUs) despite having a low mortality and good prognosis. Current risk stratification is based primarily on acidosis, but it has been suggested that hyperosmolarity may also be an important marker of increased severity. Our aim was to evaluate the relationship between raised serum osmolarity and adverse clinical outcomes in ICU admissions for ketoacidosis.

METHODS

Retrospective review of prospectively collected data for adult admissions with ketoacidosis in the Australian and New Zealand Intensive Care Society Adult Patient Database over a 15-year period (2004-2018). Exclusions were readmissions and records with critical missing data. Serum hyperosmolarity was defined as > 320 mosm/l. The primary outcome was hospital mortality; secondary outcomes were ICU mortality and other adverse clinical events.

RESULTS

Some 17 379 admissions were included in the study population. People with hyperosmolarity had fourfold increased mortality, a higher incidence of renal failure and need for mechanical ventilation, and prolonged ICU and hospital length of stay. The relationship with mortality remained highly significant even after adjusting for severity of acidosis, hospital type, year of admission, time to ICU, and a modified Australia and New Zealand Risk of Death propensity score.

CONCLUSIONS

Although adults with ketoacidosis have a good prognosis overall, hyperosmolarity was independently associated with a significantly higher incidence of multiple adverse outcomes including mortality. Whether or not this is directly causal, it may have practical applications to improve risk stratification and identify individuals at risk of adverse outcomes.

Diabetic ketoacidosis: A consensus statement of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology and Pediatric Diabetoloy (SIEDP)

BACKGROUND AND AIM

Diabetic ketoacidosis (DKA) is a serious medical emergency once considered typical of type 1 diabetes (T1DM), but now reported to occur in type 2 and GDM patients as well. DKA can cause severe complications and even prove fatal. The aim of our study was to review recent international and national guidelines on diagnosis, clinical presentation and treatment of diabetic ketoacidosis, to provide practical clinical recommendations.

METHODS AND RESULTS

Electronic databases (MEDLINE (via PUB Med), Scopus, Cochrane library were searched for relevant literature. Most international and national guidelines indicate the same accurate flow chart to diagnose, to evaluate from clinical and laboratory point of view, and treat diabetic ketoacidosis.

CONCLUSION

Prompt diagnosis, rapid execution of laboratory analysis and correct treatment are imperative to reduce the mortality related to diabetic ketoacidosis. These recommendations are designed to help healthcare professionals reduce the frequency and burden of DKA.

Corrected sodium levels for hyperglycemia is a better predictor than measured sodium levels for clinical outcomes among patients with extreme hyperglycemia

BACKGROUND

Abnormal serum sodium levels in various diseases increase mortality; however, hyperglycemia depresses serum sodium concentration significantly. This study aimed to evaluate the clinical impact of measured serum sodium levels and corrected sodium levels among patients with severe hyperglycemia.

METHODS

Patients with blood glucose levels ≥500 mg/dL visiting the emergency department between July 2008 and September 2010 were enrolled retrospectively. The participants were divided into five groups for measured sodium levels and five groups for corrected sodium levels according to blood glucose levels. Multivariate Cox regression was used. The primary outcome was all-cause 90-day mortality. Secondary outcomes included rate of intensive care unit hospitalization, respiratory failure, and renal failure.

RESULTS

A total of 755 patients with severe hyperglycemia were enrolled, and the 90-day mortality was 17.2%. Compared with the reference group, the 90-day mortality was higher in the patients with measured hypernatremia (adjusted hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.39-5.87), corrected hyponatremia (adjusted HR, 3.56; 95% CI, 1.44-8.80), and severe corrected hypernatremia (adjusted HR, 2.68; 95% CI, 1.28-5.62). However, patients with severe measured hyponatremia did not show increased mortality (adjusted HR, 1.67; 95% CI, 0.84-3.32).

CONCLUSION

Among patients with severe hyperglycemia, corrected sodium level is a better indicator of clinical outcomes compared with measured sodium levels, especially in this population with measured hyponatremia.

Management of Diabetic Ketoacidosis in Adults: A Narrative Review

Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death in patients with diabetes mellitus. DKA more commonly occurs among those with type 1 diabetes, yet almost a third of the cases occur among those with type 2 diabetes. Although mortality rates from DKA have declined to low levels in general, it continues to be high in many developing countries. DKA is characterized by hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states. The most common precipitating causes for DKA include infections, new diagnosis of diabetes and nonadherence to insulin therapy. Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA. Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers. New approaches such as extended availability of phone services, use of telemedicine and utilization of public campaigns can provide further support for the prevention of DKA.

Hyperglycemic hyperosmolar state in a chimpanzee (Pan troglodytes)

A 19-year-old female chimpanzee (Pan troglodytes) presented for cachexia, acute weakness, hyporexia, icterus, and polyuria. The animal was diagnosed with a hyperglycemic hyperosmolar state, which is a well-recognized syndrome in diabetic humans that is rarely diagnosed in animals. This case documents an important and likely under-reported syndrome in non-human primates.

Cardiovascular Risk Indices and Their Impact on Outcome in Patients with Hyperglycaemic Emergencies in a Nigerian Hospital

BACKGROUND

High sensitivity C-reactive protein (hsCRP) and Plasminogen Activator Inhibitor-1 (PAI-1) are recognised independent novel risk factors for cardiovascular disease. Few studies have assessed cardiovascular risk factors in patients with hyperglycaemic emergencies (HE), despite it being a major cause of death in diabetics.

OBJECTIVE

The objective of this study was to determine cardiovascular risk indices in patients with hyperglycaemic emergencies and related these with outcome.

METHODS

This cross sectional study involved 45 patients that presented with HE and 45 age and sex matched diabetics without HE who served as controls. Historical features, physical findings and laboratory parameters including hsCRP and PAI-1 were compared between subjects and controls.

RESULTS

The mean values of serum hsCRP and PAI-1 were significantly higher in patients with HE compared to diabetic control. (49.52 ± 13.6 vs. 2.4 ± 1.35, 51.2 ± 28.7 vs. 33.2 ± 10.7 respectively). Traditional cardiovascular risk factors such as HbA1c, Atherogenic Index and microalbuminuria were also significantly higher in them. Mortality was associated with increasing age, higher values of waist circumference, pulse rate, respiratory rate, hsCRP, Atherogenic index and lower blood pressure and HDL values.

CONCLUSION

Cardiovascular risk indices are higher in patients with HE.

Effect of Adding Insulin Glargine on Glycemic Control in Critically Ill Patients Admitted to Intensive Care Units: A Prospective Randomized Controlled Study

OBJECTIVE

We aimed to examine the effects of adding a longer-acting insulin glargine to existing glucose control on reducing blood-glucose fluctuations in an intensive care unit (ICU).

METHODS

A total of 110 patients randomly received adjuvant insulin glargine 15 IU/day (glargine) or placebo (control), in addition to daily infusion of insulin to maintain glucose levels at a target of 140-180 mg/dL. End points were mean and variance of blood glucose and frequency of hypoglycemia, hyperglycemia, ICU stay, and mortality. Data were analyzed with repeated-measures ANOVA and Mann-Whitney U test.

RESULTS

Average daily glucose level was significantly less in the glargine group than controls (P<0.0001), while there was no difference in daily variance in blood glucose between the two groups. The duration of glucose concentrations being within the target range was identical between the glargine and control groups (16.6±4.9 vs 16.4±4.6 hours/day, P=0.844) during the 7 days of admission. The frequency of hypoglycemia was greater in the glargine group and total duration of hyperglycemia (>180 mg/dL) much longer among controls (P<0.001). Similar mortality rates were observed in both groups, while ICU length of stay was 2 days shorter in the glargine group.

CONCLUSION

Addition of insulin glargine to routine protocols more effectively reduces glucose levels and decreases incidence of hyperglycemic episodes and regular insulin usage. This adjustment may be associated with decreases in duration of ICU stay or increases in hypoglycemic events.

Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study

Background

Guidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type.

Methods

Multicentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time.

Results

Of 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups.

Conclusions

Rates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0567-y) contains supplementary material, which is available to authorized users.

Intravenous fluid bolus rates and pediatric diabetic ketoacidosis resolution

BACKGROUND

Recent data have challenged the notion that rapid intravenous fluid administration results in adverse neurologic outcomes in children with diabetic ketoacidosis (DKA). While many physicians still administer a cautious 10 cc/kg bolus of intravenous fluids for pediatric DKA patients, there may be benefits to using a larger bolus.

METHODS

This was a retrospective chart review of all pediatric patients with DKA presenting to a single emergency department (ED) between 2013 and 2015. Patients who received a bolus of 10 cc/kg or less in the ED were compared to patients who received >10 cc/kg of fluids. The primary outcome was the difference in hospital length-of-stay between the two groups. Secondarily, we compared groups with regards to the time to bicarbonate normalization.

RESULTS

In sum, 170 pediatric DKA ED visits were analyzed. Patients who received a 10 cc/kg bolus or less of fluids in the ED had a mean hospital length-of-stay > that was 0.38 days longer (95% CI: 0.006 to 0.75 days) than those who received >10 cc/kg. On multivariable regression analysis, the difference between groups was diminished and no longer statistically significant. The time to bicarbonate normalization was 0.12 days longer (95% CI -0.029 to 0.27) in the 10 cc/kg or less group than the >10 cc/kg group.

CONCLUSIONS

After adjustment for confounders, no statistically significant differences in outcomes were seen in pediatric DKA patients who received a 10 cc/kg bolus or less compared to those who received a larger initial bolus.

Endocrine Emergencies With Neurologic Manifestations

PURPOSE OF REVIEW

This article provides an overview of endocrine emergencies with potentially devastating neurologic manifestations that may be fatal if left untreated. Pituitary apoplexy, adrenal crisis, myxedema coma, thyroid storm, acute hypercalcemia and hypocalcemia, hyperglycemic emergencies (diabetic ketoacidosis and hyperglycemic hyperosmolar state), and acute hypoglycemia are discussed, with an emphasis on identifying the signs and symptoms as well as diagnosing and managing these clinical entities.

RECENT FINDINGS

To identify the optimal management of endocrine emergencies, using formal clinical diagnostic criteria and grading scales such as those recently proposed for pituitary apoplexy will be beneficial in future prospective studies. A 2015 prospective study in patients with adrenal insufficiency found a significant number of adrenal crisis-related deaths despite all study patients receiving standard care and being educated on crisis prevention strategies, highlighting that current prevention strategies and medical management remain suboptimal.

SUMMARY

Early diagnosis and prompt treatment of endocrine emergencies are essential but remain challenging because of a lack of objective diagnostic tools. The optimal management is also unclear as prospective and randomized studies are lacking. Additional research is needed for these clinical syndromes that can be fatal despite intensive medical intervention.

Evaluation of NovoRapid infusion as a treatment option in the management of diabetic ketoacidosis

This study evaluates the clinical efficacy and safety of NovoRapid (insulin aspart) compared to Actrapid™ (human neutral insulin) for diabetic ketoacidosis (DKA). In this retrospective study involving 40 patients, no statistically significant differences were observed between biochemical variables, infusion duration or complications in patients treated with insulin aspart or human neutral insulin. These results support the use of insulin aspart as an effective and safe alternative to human neutral insulin in DKA.

End-Stage Renal Disease Increases Rates of Adverse Glucose Events When Treating Diabetic Ketoacidosis or Hyperosmolar Hyperglycemic State

IN BRIEF Treatment guidelines for diabetic emergencies are well described in patients with normal to moderately impaired kidney function. However, management of patients with end-stage renal disease (ESRD) is an ongoing challenge. This article describes a retrospective study comparing the rates of adverse glucose events (defined as hypoglycemia or a decrease in glucose >200 mg/dL/h) between patients with ESRD and those with normal kidney function who were admitted with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). These results indicate that current treatment approaches to DKA or HHS in patients with ESRD are suboptimal and require further evaluation.

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

BACKGROUND

Diabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs).

OBJECTIVE

To review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes.

METHODS

Ovid Medline searches were conducted with limits "all adult" and published between "1973 to current" applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers' assessment of title, abstract, and availability.

RESULTS

A total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over "sliding scale" insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1-2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes.

CONCLUSION

There are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.

Association between hyperglycaemic crisis and long-term major adverse cardiovascular events: a nationwide population-based, propensity score-matched, cohort study

OBJECTIVE

Hyperglycaemic crisis was associated with significant intrahospital morbidity and mortality. However, the association between hyperglycaemic crisis and long-term cardiovascular outcomes remained unknown. This study aimed to investigate the association between hyperglycaemic crisis and subsequent long-term major adverse cardiovascular events (MACEs).

PARTICIPANTS AND METHODS

This population-based cohort study was conducted using data from Taiwan's National Health Insurance Research Database for the period of 1996-2012. A total of 2171 diabetic patients with hyperglycaemic crisis fit the inclusion criteria. Propensity score matching was used to match the baseline characteristics of the study cohort to construct a comparison cohort which comprised 8684 diabetic patients without hyperglycaemic crisis. The risk of long-term MACEs was compared between the two cohorts.

RESULTS

Six hundred and seventy-six MACEs occurred in the study cohort and the event rate was higher than that in the comparison cohort (31.1% vs 24.1%, p<0.001). Patients with hyperglycaemic crisis were associated with a higher risk of long-term MACEs even after adjusting for all baseline characteristics and medications (adjusted HR=1.76, 95% CI 1.62 to 1.92, p<0.001). Acute myocardial infarction had the highest adjusted HR (adjusted HR=2.19, 95% CI 1.75 to 2.75, p<0.001) in the four types of MACEs, followed by congestive heart failure (adjusted HR=1.97, 95% CI 1.70 to 2.28, p<0.001). Younger patients with hyperglycaemic crisis had a higher risk of MACEs than older patients (adjusted HR=2.69 for patients aged 20-39 years vs adjusted HR=1.58 for patients aged >65 years).

CONCLUSIONS

Hyperglycaemic crisis was significantly associated with long-term MACEs, especially in the young population. Further prospective longitudinal study should be conducted for validation.

Venous serum bicarbonate concentration predicts arterial pH in adults with diabetic ketoacidosis

OBJECTIVE

The initial assessment of metabolic acidosis in subjects with diabetic ketoacidosis (DKA) is arterial blood gas analysis. This process is expensive, painful, and technically difficult. Furthermore, blood gas analysis may not be available in some facilities, especially in developing countries where DKA-associated morbidity and mortality remain high. Therefore, we investigated the utility of venous bicarbonate concentration obtained from a basic metabolic panel in predicting arterial pH in adults with DKA.

METHODS

We performed a retrospective analysis of clinical and biochemical data of 396 adults admitted to 2 community teaching hospitals with DKA. We determined the correlation between arterial pH and venous serum parameters. Using multiple logistic regression, we obtained a predictive formula for arterial pH from serum venous bicarbonate level.

RESULTS

The patient population was 59.0% male and had a mean age of 36.7 ± 13.3 years. We derived that arterial pH = 6.97 + (0.0163 x bicarbonate), and by applying this equation, we determined that serum venous bicarbonate concentration of ≤20.6 mEq/L predicted arterial pH ≤7.3 with over 95% sensitivity and 92% accuracy.

CONCLUSION

Venous serum bicarbonate obtained from the basic metabolic panel is an affordable and reliable way of estimating arterial pH in adults with DKA. Validation of this formula in a prospective study would offer a more accessible means of estimating metabolic acidosis in adults with DKA, especially in developing countries where DKA incidence and mortality remain high.

Bicarbonate Values for Healthy Residents Living in Cities Above 1500 Meters of Altitude: A Theoretical Model and Systematic Review

Ramirez-Sandoval, Juan C., Maria F. Castilla-Peón, José Gotés-Palazuelos, Juan C. Vázquez-García, Michael P. Wagner, Carlos A. Merelo-Arias, Olynka Vega-Vega, Rodolfo Rincón-Pedrero, and Ricardo Correa-Rotter. Bicarbonate values for healthy residents living in cities above 1500 m of altitude: a theoretical model and systematic review. High Alt Med Biol. 17:85-92, 2016.-Plasma bicarbonate (HCO3(-)) concentration is the main value used to assess the metabolic component of the acid-base status. There is limited information regarding plasma HCO3(-) values adjusted for altitude for people living in cities at high altitude defined as 1500 m (4921 ft) or more above sea level. Our aim was to estimate the plasma HCO3(-) concentration in residents of cities at these altitudes using a theoretical model and compare these values with HCO3(-) values found on a systematic review, and with those venous CO2 values obtained in a sample of 633 healthy individuals living at an altitude of 2240 m (7350 ft). We calculated the PCO2 using linear regression models and calculated plasma HCO3(-) according to the Henderson-Hasselbalch equation. Results show that HCO3(-) concentration falls as the altitude of the cities increase. For each 1000 m of altitude above sea level, HCO3(-) decreases to 0.55 and 1.5 mEq/L in subjects living at sea level with acute exposure to altitude and in subjects acclimatized to altitude, respectively. Estimated HCO3(-) values from the theoretical model were not different to HCO3(-) values found in publications of a systematic review or with venous total CO2 measurements in our sample. Altitude has to be taken into consideration in the calculation of HCO3(-) concentrations in cities above 1500 m to avoid an overdiagnosis of acid-base disorders in a given individual.

The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management

The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic burden of diabetic ketoacidosis have continued to rise but its mortality has decreased to less than 1% in good centers. Improved outcome is attributable to a better understanding of the pathophysiology of the disease and widespread application of treatment guidelines. In this review, we present the changes that have occurred over the years, highlighting the evidence behind the recommendations that have improved outcome. We begin with a discussion of the precipitants and pathogenesis of DKA as a prelude to understanding the rationale for the recommendations. A brief review of ketosis-prone type 2 diabetes, an update relating to the diagnosis of DKA and a future perspective are also provided.

Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial

BACKGROUND

The optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown.

OBJECTIVE

Our aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization.

METHODS

We performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each).

RESULTS

After adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0-3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2-5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6-2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4-1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4-1.5; p = 0.5) did not differ between treatment groups.

CONCLUSIONS

Higher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.

Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis

BACKGROUND

Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of uncontrolled diabetes that mainly occurs in individuals with autoimmune type 1 diabetes, but it is not uncommon in some people with type 2 diabetes. The treatment of DKA is traditionally accomplished by the administration of intravenous infusion of regular insulin that is initiated in the emergency department and continued in an intensive care unit or a high-dependency unit environment. It is unclear whether people with DKA should be treated with other treatment modalities such as subcutaneous rapid-acting insulin analogues.

OBJECTIVES

To assess the effects of subcutaneous rapid-acting insulin analogues for the treatment of diabetic ketoacidosis.

SEARCH METHODS

We identified eligible trials by searching MEDLINE, PubMed, EMBASE, LILACS, CINAHL, and the Cochrane Library. We searched the trials registers WHO ICTRP Search Portal and ClinicalTrials.gov. The date of last search for all databases was 27 October 2015. We also examined reference lists of included randomised controlled trials (RCTs) and systematic reviews, and contacted trial authors.

SELECTION CRITERIA

We included trials if they were RCTs comparing subcutaneous rapid-acting insulin analogues versus standard intravenous infusion in participants with DKA of any age or sex with type 1 or type 2 diabetes, and in pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed studies for risk of bias, and evaluated overall study quality utilising the GRADE instrument. We assessed the statistical heterogeneity of included studies by visually inspecting forest plots and quantifying the diversity using the I² statistic. We synthesised data using random-effects model meta-analysis or descriptive analysis, as appropriate.

MAIN RESULTS

Five trials randomised 201 participants (110 participants to subcutaneous rapid-acting insulin analogues and 91 to intravenous regular insulin). The criteria for DKA were consistent with the American Diabetes Association criteria for mild or moderate DKA. The underlying cause of DKA was mostly poor compliance with diabetes therapy. Most trials did not report on type of diabetes. Younger diabetic participants and children were underrepresented in our included trials (one trial only). Four trials evaluated the effects of the rapid-acting insulin analogue lispro, and one the effects of the rapid-acting insulin analogue aspart. The mean follow-up period as measured by mean hospital stay ranged between two and seven days. Overall, risk of bias of the evaluated trials was unclear in many domains and high for performance bias for the outcome measure time to resolution of DKA.No deaths were reported in the included trials (186 participants; 3 trials; moderate- (insulin lispro) to low-quality evidence (insulin aspart)). There was very low-quality evidence to evaluate the effects of subcutaneous insulin lispro versus intravenous regular insulin on the time to resolution of DKA: mean difference (MD) 0.2 h (95% CI -1.7 to 2.1); P = 0.81; 90 participants; 2 trials. In one trial involving children with DKA, the time to reach a glucose level of 250 mg/dL was similar between insulin lispro and intravenous regular insulin. There was very low-quality evidence to evaluate the effects of subcutaneous insulin aspart versus intravenous regular insulin on the time to resolution of DKA: MD -1 h (95% CI -3.2 to 1.2); P = 0.36; 30 participants; 1 trial. There was low-quality evidence to evaluate the effects of subcutaneous rapid-acting insulin analogues versus intravenous regular insulin on hypoglycaemic episodes: 6 of 80 insulin lispro-treated participants compared with 9 of 76 regular insulin-treated participants reported hypoglycaemic events; risk ratio (RR) 0.59 (95% CI 0.23 to 1.52); P = 0.28; 156 participants; 4 trials. For insulin aspart compared with regular insulin, RR for hypoglycaemic episodes was 1.00 (95% CI 0.07 to 14.55); P = 1.0; 30 participants; 1 trial; low-quality evidence. Socioeconomic effects as measured by length of mean hospital stay for insulin lispro compared with regular insulin showed a MD of -0.4 days (95% CI -1 to 0.2); P = 0.22; 90 participants; 2 trials; low-quality evidence and for insulin aspart compared with regular insulin 1.1 days (95% CI -3.3 to 1.1); P = 0.32; low-quality evidence. Data on morbidity were limited, but no specific events were reported for the comparison of insulin lispro with regular insulin. No trial reported on adverse events other than hypoglycaemic episodes, and no trial investigated patient satisfaction.

AUTHORS' CONCLUSIONS

Our review, which provided mainly data on adults, suggests on the basis of mostly low- to very low-quality evidence that there are neither advantages nor disadvantages when comparing the effects of subcutaneous rapid-acting insulin analogues versus intravenous regular insulin for treating mild or moderate DKA.

Severe Ketoacidosis (pH ≤ 6.9) in Type 2 Diabetes: More Frequent and Less Ominous Than Previously Thought

Diabetic ketoacidosis is a life-threatening acute metabolic complication of uncontrolled diabetes. Severe cases of DKA (pH ≤ 7.00, bicarbonate level ≤ 10.0, anion gap > 12, positive ketones, and altered mental status) are commonly encountered in patients with type 1 diabetes and are thought to carry an ominous prognosis. There is not enough information on the clinical course of severely acidotic type 2 diabetes (pH ≤ 6.9) patients with DKA, possibly because this condition is rarely seen in developed countries. In this series, we present 18 patients with type 2 diabetes, DKA, and a pH ≤ 6.9 that presented to a tertiary university hospital over the past 11 years. The objective was to describe their clinical characteristics, the triggering cause, and emphasis on treatment, evolution, and outcomes. The majority of the patients were female (61%). Mean age was 40.66 years (23–59). The patients had been first diagnosed with type 2 diabetes on average 5.27 ± 3.12 years before admission. Glutamic acid decarboxylase (GAD65) antibodies were negative in all patients. The origin of DKA could be attributed to two main causes: treatment omission in 8 (44.4%) patients and infections in 7 (38.8%) patients. The most common symptoms described were general malaise, dyspnea, altered mental status, and abdominal pain. Mean serum glucose on admission was 613.8 ± 114.5 mg/dL. Mean venous pH was 6.84 ± 0.03 with an anion gap of 30.3 ± 2.9 and a venous HCO₃ level of 3.62 ± 1.35 mmol/L. All patients had acute renal failure on admission, with a mean serum creatinine of 1.57 ± 0.35 mg/dL compared to 0.55 ± 0.21 mg/dL at discharge. All patients received regular insulin infusion, aggressive fluid repletion, and 12 patients (66%) received bicarbonate infusion. Mean total insulin infusion dose was 181.7 ± 90.4 U (on average 0.14 ± 0.05 U/Kg/h). Mean time on infusion was 24.4 ± 12.6 hours. We recorded no mortality in this case series. Mean in-hospital stay was 5.0 ± 4.1 days. In conclusion, very severe DKA in type 2 diabetes is not uncommon in our population, shares many features with non-very-severe cases of DKA (bicarbonate therapy did not make a difference in mortality), and can be managed following standard published or institutional guidelines.

Prospective randomized trial of insulin glargine in acute management of diabetic ketoacidosis in the emergency department: a pilot study

OBJECTIVES

The objective was to determine the efficacy of coadministration of subcutaneous (SQ) insulin glargine in combination with intravenous (IV) insulin for treating diabetic ketoacidosis (DKA).

METHODS

This was a prospective, randomized, controlled trial comparing coadministration of insulin glargine and IV insulin (experimental) with IV insulin (standard care control). The setting was emergency departments (EDs) in two hospitals in Houston, Texas. Patients presenting with blood sugar ≥ 200 mg/dL, pH ≤ 7.3, bicarbonate (HCO3 ) ≤ 18 mg/dL, ketonemia or ketonuria, and anion gap ≥ 16 between November 2012 and April 2013 were enrolled. All patients received IV insulin. Additionally, the experimental group was given SQ insulin glargine within 2 hours of diagnosis. Upon closure of anion gap, patients in the control group were subsequently transitioned to long-acting insulin. In the study group, IV insulin was discontinued and long-acting SQ insulin was reinstituted 24 hours after initial introduction. The primary outcome of time to closure of anion gap (TCAG) was compared between groups using a general linear model (GLM), adjusting for initial anion gap, etiology, and presence of comorbidities. Similarly, the secondary outcome hospital length of stay (LOS) was adjusted for age, etiology, and hospital site in the GLM. Rate of hypoglycemia and intensive care unit (ICU) admission was compared using Fisher's exact test while ICU LOS was compared using Wilcoxon's two-sample test.

RESULTS

A total of 40 patients were enrolled in this pilot trial. The estimated mean TCAG was 10.2 hours (SE ± 6.8 hours) in the experimental group and 11.6 hours (SE ± 6.4 hours) in the control group (p = 0.63). The estimated mean hospital LOS was 3.9 days (SE ± 3.4 days) in the experimental group and 4.8 days (SE ± 3.6 days) in the control group (p = 0.66). Incidents of hypoglycemia, rates of ICU admission, and ICU LOS were similar between the groups.

CONCLUSIONS

Coadministration of glargine in combination with an insulin infusion in the acute management of DKA is feasible. Further study is needed to determine the true efficacy in terms of TCAG and hospital LOS.