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Barski L, Golbets E, Jotkowitz A, Schwarzfuchs D. Management of diabetic ketoacidosis. Eur J Intern Med 2023; 117:38-44. [PMID: 37419787 DOI: 10.1016/j.ejim.2023.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/09/2023]
Abstract
Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness. There are still controversies regarding certain aspects of DKA management. Different society guidelines have inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA and provide our perspective on these issues. Moreover, we believe that special patient factors and comorbidities should receive more careful attention and consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach and require tailored management strategies. However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, we aim to address unique circumstances and provide an approach to managing complex patients with specific conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate on aspects of latest research with a perspective towards future developments and modifications.
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Affiliation(s)
- Leonid Barski
- Department of Internal Medicine F, Soroka Univerity Medical Center, P.O.Box 151, Beer-Sheva 84101, Israel.
| | - Evgeny Golbets
- Department of Internal Medicine F, Soroka Univerity Medical Center, P.O.Box 151, Beer-Sheva 84101, Israel
| | - Alan Jotkowitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Dan Schwarzfuchs
- Department of Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
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2
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Al-Reshed F, Sindhu S, Al Madhoun A, Bahman F, AlSaeed H, Akhter N, Malik MZ, Alzaid F, Al-Mulla F, Ahmad R. Low carbohydrate intake correlates with trends of insulin resistance and metabolic acidosis in healthy lean individuals. Front Public Health 2023; 11:1115333. [PMID: 37006572 PMCID: PMC10061153 DOI: 10.3389/fpubh.2023.1115333] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/16/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction Both obesity and a poor diet are considered major risk factors for triggering insulin resistance syndrome (IRS) and the development of type 2 diabetes mellitus (T2DM). Owing to the impact of low-carbohydrate diets, such as the keto diet and the Atkins diet, on weight loss in individuals with obesity, these diets have become an effective strategy for a healthy lifestyle. However, the impact of the ketogenic diet on IRS in healthy individuals of a normal weight has been less well researched. This study presents a cross-sectional observational study that aimed to investigate the effect of low carbohydrate intake in healthy individuals of a normal weight with regard to glucose homeostasis, inflammatory, and metabolic parameters. Methods The study included 120 participants who were healthy, had a normal weight (BMI 25 kg/m2), and had no history of a major medical condition. Self-reported dietary intake and objective physical activity measured by accelerometry were tracked for 7 days. The participants were divided into three groups according to their dietary intake of carbohydrates: the low-carbohydrate (LC) group (those consuming <45% of their daily energy intake from carbohydrates), the recommended range of carbohydrate (RC) group (those consuming 45-65% of their daily energy intake from carbohydrates), and the high-carbohydrate (HC) group (those consuming more than 65% of their daily energy intake from carbohydrates). Blood samples were collected for the analysis of metabolic markers. HOMA of insulin resistance (HOMA-IR) and HOMA of β-cell function (HOMA-β), as well as C-peptide levels, were used for the evaluation of glucose homeostasis. Results Low carbohydrate intake (<45% of total energy) was found to significantly correlate with dysregulated glucose homeostasis as measured by elevations in HOMA-IR, HOMA-β% assessment, and C-peptide levels. Low carbohydrate intake was also found to be coupled with lower serum bicarbonate and serum albumin levels, with an increased anion gap indicating metabolic acidosis. The elevation in C-peptide under low carbohydrate intake was found to be positively correlated with the secretion of IRS-related inflammatory markers, including FGF2, IP-10, IL-6, IL-17A, and MDC, but negatively correlated with IL-3. Discussion Overall, the findings of the study showed that, for the first time, low-carbohydrate intake in healthy individuals of a normal weight might lead to dysfunctional glucose homeostasis, increased metabolic acidosis, and the possibility of triggering inflammation by C-peptide elevation in plasma.
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Affiliation(s)
- Fatema Al-Reshed
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Sardar Sindhu
- Animal and Imaging Core Facility, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Ashraf Al Madhoun
- Animal and Imaging Core Facility, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Fatemah Bahman
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Halemah AlSaeed
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Nadeem Akhter
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Md Zubbair Malik
- Genetics and Bioinformatics, Dasman Diabetes Institute, Dasman, Kuwait
| | - Fawaz Alzaid
- Institute Necker Enfants Malades (INEM), French Institute of Health and Medical Research (INSERM), Immunity and Metabolism of Diabetes (IMMEDIAB), Université de Paris Cité, Paris, France
| | - Fahd Al-Mulla
- Genetics and Bioinformatics, Dasman Diabetes Institute, Dasman, Kuwait
| | - Rasheed Ahmad
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
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3
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Lim BL, Lee WF, Lee B, Chung YEL, Loo KV. Subcutaneous fast-acting insulin analogues, alone or in combination with long-acting insulin, versus intravenous regular insulin infusion in patients with diabetic ketoacidosis: protocol for an updated systematic review and meta-analysis of randomised trials. BMJ Open 2023; 13:e070131. [PMID: 36764729 PMCID: PMC9923333 DOI: 10.1136/bmjopen-2022-070131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is traditionally managed using intravenous regular insulin infusion (RII) in intensive care unit (ICU)/high dependency unit (HDU). Subcutaneous fast-acting insulin analogues (FAIAs) may help to manage DKA outside ICU/HDU. Furthermore, combining subcutaneous long-acting insulin (LAI) with subcutaneous FAIAs may accelerate ketoacidosis resolution. The latest (2016) Cochrane review was inconclusive regarding subcutaneous FAIAs versus intravenous RII in DKA. It was limited by small sample sizes, unclear risk of bias (RoB) in primary trials and did not examine subcutaneous FAIAs with subcutaneous LAI versus intravenous RII in DKA. We report the protocol for an updated meta-analysis on the safety and benefits of subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA. METHODS AND ANALYSIS We will search Medline, Embase, CINAHL and Cochrane Library, from inception until December 2022, without language restrictions, for randomised trials on subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA. We also search ClinicalTrials.gov, ClinicalTrialsRegister.eu and reference lists of included trials. Primary outcomes include all-cause in-hospital mortality, time to DKA resolution, in-hospital DKA recurrence and hospital readmission for DKA post-discharge. Secondary outcomes include resource utilisation and patient satisfaction. Safety outcomes include important complications of DKA and insulin. Reviewers will extract data, assess overall RoB and quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation. We will assess statistical heterogeneity by visually inspecting forest plots and the I2 statistic. We will synthesise data using the random-effects model. Predefined subgroup analyses are: mild versus moderate versus severe DKA; age <20 vs ≥20 years; pregnant versus non-pregnant; infective versus non-infective DKA precipitating cause; subcutaneous FAIAs alone versus subcutaneous FAIAs and subcutaneous LAI; and high versus low overall RoB. We will also perform trial sequential analysis for primary outcomes. ETHICS AND DISSEMINATION Ethics board approval is not required. Results will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022369518.
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Affiliation(s)
- Beng Leong Lim
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
| | - Wei Feng Lee
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
| | - Berlin Lee
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
| | - Yan Ee Lynette Chung
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
| | - Kee Vooi Loo
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
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4
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Kaser S, Sourij H, Clodi M, Schneeweiß B, Laggner AN, Luger A. [Treatment of acute diabetic metabolic crises in adults (Update 2023) : Hyperglycemic hyperosmolar state and ketoacidotic metabolic disorder]. Wien Klin Wochenschr 2023; 135:237-241. [PMID: 37101045 PMCID: PMC10133381 DOI: 10.1007/s00508-023-02174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/28/2023]
Abstract
Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) represent potentially life-threatening situations in adults. Therefore, rapid comprehensive diagnostic and therapeutic measures with close monitoring of vital and laboratory parameters are required. The treatment of DKA and HHS is essentially the same and replacement of the mostly substantial fluid deficit with several liters of a physiological crystalloid solution is the first and most important step. Serum potassium concentrations need to be carefully monitored to guide its substitution. Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion. Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range.
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Affiliation(s)
- Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Martin Clodi
- Abteilung für Innere Medizin, Krankenhaus Barmherzige Brüder Linz, Linz, Österreich
| | - Bruno Schneeweiß
- Intensivstation, Klinische Abteilung für Gastroenterologie und Hepatologie Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Anton N Laggner
- Universitätsklinik für Notfallmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Anton Luger
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Spitalgasse 23, 1090, Wien, Österreich.
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Welter KJ, Marquez JL, Marshik PL, Yao MV, Bickel ES. Evaluation of Early Insulin Glargine Administration in the Treatment of Pediatric Diabetic Ketoacidosis. J Pediatr Pharmacol Ther 2023; 28:149-155. [PMID: 37139251 PMCID: PMC10150908 DOI: 10.5863/1551-6776-28.2.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/07/2022] [Indexed: 05/05/2023]
Abstract
OBJECTIVE In the management of diabetic ketoacidosis (DKA), the standard of care is to administer insulin glargine after ketoacidosis has resolved and the patient is transitioning from intravenous (IV) insulin to subcutaneous insulin; however, there is evidence to suggest that earlier administration of insulin glargine may accelerate resolution of ketoacidosis. The objective of this research is to determine the efficacy of early subcutaneous insulin glargine on time to resolution of ketoacidosis in children with moderate to severe DKA. METHODS This retrospective chart review evaluated children age 2 to 21 years old admitted for moderate to severe DKA who received insulin glargine within 6 hours of hospital admission (early insulin glargine) compared with those who received insulin glargine greater than 6 hours from admission (late insulin glargine). The primary outcome was duration of time the patient received IV insulin. RESULTS A total of 190 patients were included. The median time on IV insulin was lower in patients who received early insulin glargine compared with those who received late insulin glargine (17.0 [IQR, 14-22.8] vs 22.9 hours [IQR, 4.3-29.3]; p = 0.0006). Resolution of DKA was faster in patients who received early insulin glargine compared with those who received late insulin glargine (median, 13.0 [IQR, 9.8-16.8] vs 18.2 hours [IQR, 12.5-27.6]; p = 0.005). Length of pediatric intensive care unit (PICU) and hospital stay and incidences of hypoglycemia and hypokalemia were similar between the 2 groups. CONCLUSIONS Children with moderate to severe DKA who received early insulin glargine had a significantly lower time on IV insulin, as well as significantly faster time to resolution of DKA when compared with those who received late insulin glargine. There were no significant differences observed in hospital stay and rates of hypoglycemia and hypokalemia.
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Affiliation(s)
- Kelli J Welter
- Department of Pharmacy (KW, JM, EB), University of New Mexico Hospital, Albuquerque, NM
| | - Jessica L Marquez
- Department of Pharmacy (KW, JM, EB), University of New Mexico Hospital, Albuquerque, NM
| | | | - Michael V Yao
- Department of Pediatrics Division of Endocrinology (MY), University of New Mexico School of Medicine, Albuquerque, NM
| | - Ellen S Bickel
- Department of Pharmacy (KW, JM, EB), University of New Mexico Hospital, Albuquerque, NM
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Blank SP, Blank RM, Campbell L. What Is the Optimal Speed of correction of the Hyperosmolar Hyperglycemic State in Diabetic Ketoacidosis? An Observational Cohort Study of U.S. Intensive Care Patients. Endocr Pract 2022; 28:875-883. [PMID: 35688365 DOI: 10.1016/j.eprac.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The international guidelines for the treatment of diabetic ketoacidosis (DKA) advise against rapid changes in osmolarity and glucose; however, the optimal rates of correction are unknown. We aimed to evaluate the rates of change in tonicity and glucose level in intensive care patients with DKA and their relationship with mortality and altered mental status. METHODS This is an observational cohort study using 2 publicly available databases of U.S. intensive care patients (Medical Information Mart for Intensive Care-IV and Electronic Intensive Care Unit), evaluating adults with DKA and associated hyperosmolarity (baseline Osm ≥300 mOsm/L). The primary outcome was hospital mortality. The secondary neurologic outcome used a composite of diagnosed cerebral edema or Glasgow Coma Scale score of ≤12. Multivariable regression models were used to control for confounding factors. RESULTS On adjusted analysis, patients who underwent the most rapid correction of up to approximately 3 mmol/L/hour in tonicity had reduced mortality (n = 2307; odds ratio [OR], 0.21; overall P < .001) and adverse neurologic outcomes (OR, 0.44; P < .001). Faster correction of glucose levels up to 5 mmol/L/hour (90 mg/dL/hour) was associated with improvements in mortality (n = 2361; OR, 0.24; P = .020) and adverse neurologic events (OR, 0.52; P = .046). The number of patients corrected significantly faster than these rates was low. A maximal hourly rate of correction between 2 and 5 mmol/L for tonicity was associated with the lowest mortality rate on adjusted analysis. CONCLUSION Based on large-volume observational data, relatively rapid correction of tonicity and glucose level was associated with lower mortality and more favorable neurologic outcomes. Avoiding a maximum hourly rate of correction of tonicity >5 mmol/L may be advisable.
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Affiliation(s)
- Sebastiaan P Blank
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Northern Territory, Australia.
| | - Ruth M Blank
- Royal Darwin Hospital, Tiwi, Darwin, Northern Territory, Australia
| | - Lewis Campbell
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Northern Territory, Australia; Flinders University, Adelaide, Australia; Menzies School of Health Research, Royal Darwin Hospital Campus, Tiwi, Northern Territory, Australia
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Lamptey R, Engmann St ST, Asante B, Yorke E, Mensah YB, Akoriyea SK, Owoo C, Lawson HJ. Atypical presentation of COVID-19 in a patient with type 2 diabetes at an urban primary care facility in Accra, Ghana. Ghana Med J 2021; 54:117-120. [PMID: 33976452 PMCID: PMC8087359 DOI: 10.4314/gmj.v54i4s.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This is a case report of a 55-year-old man with Type 2 Diabetes Mellitus who presented with progressive breathlessness, chest pain and hyperglycaemia. An initial impression of a chest infection was made. Management was initiated with antibiotics, but this was unsuccessful, and he continued to desaturate. A screen for Coronavirus Disease of 2019 (COVID-19) returned positive. There was no prodrome of fever or flu-like illness or known contact with a patient known to have COVID-19. This case is instructive as he didn't fit the typical case definition for suspected COVID-19. There is significant community spread in Ghana, therefore COVID-19 should be a differential diagnosis in patients who present with hyperglycaemia and respiratory symptoms in the absence of a febrile illness. Primary care doctors must have a high index of suspicion in cases of significant hyperglycaemia and inability to maintain oxygen saturation. Patients known to have diabetes and those not known to have diabetes may develop hyperglycaemia subsequent to COVID-19. A high index of suspicion is crucial for early identification, notification for testing, isolation, treatment, contact tracing and possible referral or coordination of care with other specialists. Early identification will protect healthcare workers and patients alike from cross-infection.
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Affiliation(s)
- Roberta Lamptey
- Family Medicine Department, Korle Bu Teaching Hospital, Accra Ghana.,Department of Community Health, University of Ghana Medical School, University of Ghana, Accra, Ghana
| | | | | | - Ernest Yorke
- Department of Medicine & Therapeutics, University of Ghana Medical School, University of Ghana, Accra, Ghana
| | - Yaw B Mensah
- Department of Radiology, University of Ghana Medical School University of Ghana, Accra, Ghana
| | | | - Christian Owoo
- Department of Anaesthesia, University of Ghana Medical School, University of Ghana, Accra, Ghana
| | - Henry J Lawson
- Department of Community Health, University of Ghana Medical School, University of Ghana, Accra, Ghana.,Ghana College of Physicians and Surgeons, Ridge, Accra, Ghana
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Long B, Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management. Am J Emerg Med 2021; 44:157-160. [PMID: 33626481 DOI: 10.1016/j.ajem.2021.02.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL. OBJECTIVE This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians. DISCUSSION EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology. CONCLUSIONS Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL 60612, United States of America
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Muneer M, Akbar I. Acute Metabolic Emergencies in Diabetes: DKA, HHS and EDKA. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1307:85-114. [PMID: 32488607 DOI: 10.1007/5584_2020_545] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.
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Affiliation(s)
| | - Ijaz Akbar
- Shukat Khanam Cancer Hospital and Research Centre, Lahore, Pakistan
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10
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Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Evaluation and Management of the Critically Ill Adult With Diabetic Ketoacidosis. J Emerg Med 2020; 59:371-383. [DOI: 10.1016/j.jemermed.2020.06.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/24/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
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Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ 2019; 365:l1114. [PMID: 31142480 DOI: 10.1136/bmj.l1114] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.
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Affiliation(s)
- Esra Karslioglu French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amy C Donihi
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mary T Korytkowski
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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12
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Kaser S, Sourij H, Clodi M, Schneeweiß B, Laggner AN, Luger A. [Treatment of acute diabetic metabolic crises in adults (Update 2019) : Hyperglycemic hyperosmolar state and ketoacidotic metabolic disorders]. Wien Klin Wochenschr 2019; 131:196-199. [PMID: 30980160 DOI: 10.1007/s00508-018-1423-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) represent potentially life-threatening situations in adults. Therefore, rapid comprehensive diagnostic and therapeutic measures with close monitoring of vital and laboratory parameters are required. The treatment of DKA and HHS is essentially the same and replacement of the mostly substantial fluid deficit with several liters of a physiological crystalloid solution is the first and most important step. Serum potassium concentrations need to be carefully monitored to guide its substitution. Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion. Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range.
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Affiliation(s)
- Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich.,Christian Doppler Labor für Insulinresistenz, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Martin Clodi
- Abteilung für Innere Medizin, Krankenhaus Barmherzige Brüder Linz, Linz, Österreich
| | - Bruno Schneeweiß
- Abteilung für Innere Medizin, Landeskrankenhaus Kirchdorf, Kirchdorf, Österreich
| | - Anton N Laggner
- Universitätsklinik für Notfallmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Anton Luger
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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[Increasing lactate levels during treatment of diabetic ketoacidosis]. Med Klin Intensivmed Notfmed 2019; 115:417-419. [PMID: 30918984 DOI: 10.1007/s00063-019-0562-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/14/2019] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
A young woman with type 1 diabetes mellitus and severe diabetic ketoacidosis was treated in an intensive care unit according to the guidelines. Only a few hours after starting the therapy, rising lactate values were diagnosed in the arterial blood gas analysis. Since there were no indications for other reasons of lactatemia, an acute refeeding syndrome caused by the insulin therapy was suspected. Thiamine and phosphate were thus replaced. With this treatment, lactate values fell, supporting the hypothesis of lactatemia due to substrate deficiency.
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Lee MH, Calder GL, Santamaria JD, MacIsaac RJ. Diabetic ketoacidosis in adult patients: an audit of factors influencing time to normalisation of metabolic parameters. Intern Med J 2018; 48:529-534. [PMID: 29316133 DOI: 10.1111/imj.13735] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute life-threatening metabolic complication of diabetes that imposes substantial burden on our healthcare system. There is a paucity of published data in Australia assessing factors influencing time to resolution of DKA and length of stay (LOS). AIMS To identify factors that predict a slower time to resolution of DKA in adults with diabetes. METHODS Retrospective audit of patients admitted to St Vincent's Hospital Melbourne between 2010 to 2014 coded with a diagnosis of 'Diabetic Ketoacidosis'. The primary outcome was time to resolution of DKA based on normalisation of biochemical markers. Episodes of DKA within the wider Victorian hospital network were also explored. RESULTS Seventy-one patients met biochemical criteria for DKA; median age 31 years (26-45 years), 59% were male and 23% had newly diagnosed diabetes. Insulin omission was the most common precipitant (42%). Median time to resolution of DKA was 11 h (6.5-16.5 h). Individual factors associated with slower resolution of DKA were lower admission pH (P < 0.001) and higher admission serum potassium level (P = 0.03). Median LOS was 3 days (2-5 days), compared to a Victorian state-wide LOS of 2 days. Higher comorbidity scores were associated with longer LOS (P < 0.001). CONCLUSIONS Lower admission pH levels and higher admission serum potassium levels are independent predictors of slower time to resolution of DKA. This may assist to stratify patients with DKA using markers of severity to determine who may benefit from closer monitoring and to predict LOS.
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Affiliation(s)
- Melissa H Lee
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Genevieve L Calder
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - John D Santamaria
- Department of Intensive Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Barski L, Brandstaetter E, Sagy I, Jotkowitz A. Basal insulin for the management of diabetic ketoacidosis. Eur J Intern Med 2018; 47:14-16. [PMID: 28864157 DOI: 10.1016/j.ejim.2017.08.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/20/2017] [Accepted: 08/27/2017] [Indexed: 01/25/2023]
Abstract
Due to its pharmacokinetic properties, it has been suggested that long-acting insulin analogues may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA for prevention of rebound hyperglycemia, particularly if there are high insulin requirements. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycemia. Several studies have investigated the use of basal insulin in the management of DKA. Studies have been instituted on pediatric patients and adult patients. These studies reveal that co-administration of basal insulin in combination with an insulin infusion in the acute management of DKA is feasible. Basal insulin co-administration with regular insulin infusion was well tolerated, associated with faster resolution of acidosis without any adverse effects; patients required a shorter duration of intravenous insulin infusion and had a lower total dose of intravenous insulin and significantly decreased hyperglycemia after discontinuation of the intravenous insulin. This could potentially lead to a shorter ICU length of stay and reduced costs in the treatment of DKA. However, this approach may be associated with an increased risk of hypokalemia. The current literature on this management approach is incomplete, due to its many limitations (retrospective nature, small sample size, nonrandomized design). Additional prospective randomized studies are needed on this new therapeutic approach in the management patients with DKA.
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Affiliation(s)
- Leonid Barski
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel.
| | - Evgenia Brandstaetter
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Iftach Sagy
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Alan Jotkowitz
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
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