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Lovegrove SS, Dubbs SB. Hyperosmolar Hyperglycemic State. Emerg Med Clin North Am 2023; 41:687-696. [PMID: 37758417 DOI: 10.1016/j.emc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Hyperosmolar hyperglycemic state (HHS) is an underrecognized diabetic emergency with high morbidity and mortality. Many features of HHS overlap with those of diabetic ketoacidosis but key differentiators for HHS are serum osmolality greater than 320 mOsm/kg, lack of metabolic acidosis, and minimal to no presence of ketones. HHS is often triggered by an underlying illness-most commonly infection but may also be triggered by stroke, acute coronary syndrome, and other acute illnesses. Treatment guidelines recommend aggressive volume-repletion of osmotic losses in addition to insulin therapy, plus treatment of the underlying cause.
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Affiliation(s)
- Spencer S Lovegrove
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor Suite 200, Baltimore, MD 21201, USA
| | - Sarah B Dubbs
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor Suite 200, Baltimore, MD 21201, USA.
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2
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Diabetic Ketoacidosis Management: Updates and Challenges for Specific Patient Population. ENDOCRINES 2022. [DOI: 10.3390/endocrines3040066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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3
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Phelan H, Hanas R, Hofer SE, James S, Landry A, Lee W, Wood JR, Codner E. Sick day management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:912-925. [PMID: 36093857 DOI: 10.1111/pedi.13415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Helen Phelan
- Pediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla Hospital, Uddevalla, and Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Petrie, Queensland, Australia
| | - Alanna Landry
- Department of Paediatrics, Oak Valley Health, Markham, Ontario, Canada
| | - Warren Lee
- Dr. Warren Lee's Paediatrics, Growth & Diabetes Centre, and KK Hospital, Singapore, Singapore
| | - Jamie R Wood
- University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ethel Codner
- Institute of Maternal and Child Research (IDIMI), School of Medicine, University of Chile, Santiago, Chile
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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5
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Algarni A. Treatment Considerations and Pharmacist Collaborative Care in Diabetic Ketoacidosis Management. J Pharmacol Pharmacother 2022. [DOI: 10.1177/0976500x221128643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Alanood Algarni
- Pharmacology and Toxicology Department, Pharmacy College, Umm Al-Qura University, Makkah, Saudi Arabia
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6
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Alshurtan KS, Alnizari O, Aldarwish H, Al-Tufaif AA. Efficacy and Safety of Intravenous Insulin in Treatment of Patient With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30721. [DOI: 10.7759/cureus.30721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/07/2022] Open
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Bacha T, Shiferaw Y, Abebaw E. Outcome of diabetic ketoacidosis among paediatric patients managed with modified DKA protocol at Tikur Anbessa specialized hospital and Yekatit 12 hospital, Addis Ababa, Ethiopia. Endocrinol Diabetes Metab 2022; 5:e363. [PMID: 36102127 PMCID: PMC9471591 DOI: 10.1002/edm2.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a serious acute complication of diabetes mellitus that carries a significant risk of mortality with delayed treatment in low-resource countries. This study aimed to determine the outcome of paediatric DKA patients' managed with a modified DKA treatment protocol using intermittent bolus subcutaneous insulin administration. METHODS A cross-sectional study design with retrospective data collection was conducted among children younger than 14 years of age admitted from January 2013 to February 2017. A modified protocol was prepared based on a reference from the international society for paediatric and adolescent diabetes and other international guidelines. Data were analysed using Statistical package for social science (SPSS) version 22.0. Descriptive statistics were performed. Binary logistic regression was used to identify associations, and significant variables were further considered for multivariate logistic regression to determine the outcome of DKA patients. RESULT Among the 190 patients, 55.5% (n = 105) were newly diagnosed. The overall average time required for resolution of DKA was 48 ± 27.8 h. Mental status on presentation (p = .001), shock on presentation (p < .01) and severity of DKA (p < .001) were found to have a significant association with the mean time for clearance of DKA. Hypoglycaemia was the most common treatment-related complication, which occurred in 23.7% of patients (n = 45) followed by hypokalaemia in 4.3% of patients (n = 8), and no patient developed cerebral oedema and death. CONCLUSION The time required for clearance of DKA was prolonged, and hypoglyceamia was a common complication for children younger than 5 years of age. The modified protocol of DKA is reasonable management for low-resource settings with further modification.
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Affiliation(s)
- Tigist Bacha
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesSt Paul Millennium Medical CollegeAddis AbabaEthiopia
| | - Yemisrach Shiferaw
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Ermias Abebaw
- Department of Pediatrics and Child Health, School of MedicineDebre Markos UniversityDebre MarkosEthiopia
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8
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Bass ME, Paavola N, Kiser TH, Wright G, Jacknin G. Evaluation of Insulin Infusion Rates for the Treatment of Diabetic Ketoacidosis in the Emergency Department. JOURNAL OF BIOSCIENCES AND MEDICINES 2022; 10:203-211. [PMID: 35386489 PMCID: PMC8983016 DOI: 10.4236/jbm.2022.103019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Objective: Methods: Results: Conclusion:
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Affiliation(s)
- Megan E. Bass
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Nicole Paavola
- Department of Pharmacy, UCHealth, University of Colorado Hospital, Aurora, CO, USA
| | - Tyree H. Kiser
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Garth Wright
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Gabrielle Jacknin
- Department of Pharmacy, UCHealth, University of Colorado Hospital, Aurora, CO, USA
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9
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Modzelewski KL, Cannavo A, Fantasia KL, Korpaisarn S, Alexanian SM. A quality improvement initiative to successfully reduce the frequency of hypoglycemia during treatment of hyperglycemic crises at an academic safety-net hospital: Insights and results. J Clin Transl Endocrinol 2021; 26:100269. [PMID: 34804807 PMCID: PMC8581574 DOI: 10.1016/j.jcte.2021.100269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/31/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Abstract
Hypoglycemia occurs frequently during treatment of hyperglycemic crisis. Development of protocols to standardize hyperglycemic crisis treatment can mitigate risk of hypoglycemia. Usability of protocols must be considered in addition to efficacy to ensure they can be followed appropriately.
Background Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are potentially life-threatening complications of diabetes. Many hospitals have developed protocols to guide the management of these conditions and align with best practices. One of the main complications encountered in the treatment of hyperglycemic crises is hypoglycemia. Methods At our institution, we undertook a review of our insulin infusion titration protocol, rates of hypoglycemia, and time to clinical resolution for patients with hyperglycemic crises. A multidisciplinary team performed a literature review and analyzed baseline hospital data with the existing protocol. With the input of multiple stakeholders, several changes were made to the titration algorithm over multiple PDSA cycles to refine the protocol. Effectiveness and safety of the protocol, as well as fidelity with the protocol, were assessed after each PDSA cycle. Results After the initial cycle, chart review showed a reduction in hypoglycemia rates of more than 50% in patients treated with the new protocol without any increase in time to resolution of DKA. A second version of the protocol was implemented to improve usability, and improvement in hypoglycemia was maintained. Conclusion Despite the fact that the initial protocol had been developed based on best practice recommendations, rates of hypoglycemia were initially high. Critical assessment of pitfalls in management allowed changes to the protocol that significantly and sustainably reduced hypoglycemia.
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10
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Chow L, Valesky W. Subcutaneous Rapid-acting Insulin Analogs for Diabetic Ketoacidosis. Acad Emerg Med 2021; 28:700-702. [PMID: 33145848 DOI: 10.1111/acem.14170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Lillian Chow
- From the Department of Medicine Division of Pulmonary and Critical Care Medicine SUNY Downstate Health Sciences University Brooklyn NY USA
| | - Walter Valesky
- and the Department of Emergency Medicine Kings County Hospital–NYC Health + Hospitals Brooklyn NY USA
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11
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Priyambada L, Wolfsdorf JI, Brink SJ, Fritsch M, Codner E, Donaghue KC, Craig ME. ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of COVID-19 and resource-limited settings-role of subcutaneous insulin. Pediatr Diabetes 2020; 21:1394-1402. [PMID: 32935435 DOI: 10.1111/pedi.13118] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/19/2020] [Accepted: 08/19/2020] [Indexed: 01/08/2023] Open
Abstract
The International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guideline 2018 for management of diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state provide comprehensive guidance for management of DKA in young people. Intravenous (IV) infusion of insulin remains the treatment of choice for treating DKA; however, the policy of many hospitals around the world requires admission to an intensive care unit (ICU) for IV insulin infusion. During the coronavirus 2019 (COVID-19) pandemic or other settings where intensive care resources are limited, ICU services may need to be prioritized or may not be appropriate due to risk of transmission of infection to young people with type 1 or type 2 diabetes. The aim of this guideline, which should be used in conjunction with the ISPAD 2018 guidelines, is to ensure that young individuals with DKA receive management according to best evidence in the context of limited ICU resources. Specifically, this guideline summarizes evidence for the role of subcutaneous insulin in treatment of uncomplicated mild to moderate DKA in young people and may be implemented if administration of IV insulin is not an option.
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Affiliation(s)
- Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stuart J Brink
- New England Diabetes and Endocrinology Center, Waltham, Massachusetts, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
| | - Kim C Donaghue
- Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Maria E Craig
- Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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12
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Gutiérrez-Ortiz CC, Concepción-Zavaleta MJ, García-Villasante EJ. Diabetic ketoacidosis treatment during COVID-19 pandemic in a country with scarce health resources. Diabetes Metab Syndr 2020; 14:1847-1848. [PMID: 32971512 PMCID: PMC7485543 DOI: 10.1016/j.dsx.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Claudia C Gutiérrez-Ortiz
- Universidad Nacional Mayor de San Marcos, Division of Endocrinology, Hospital Nacional Daniel Alcides Carrion, Lima, Peru.
| | - Marcio J Concepción-Zavaleta
- Universidad Nacional Mayor de San Marcos, Division of Endocrinology, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Eilhart J García-Villasante
- Universidad Nacional Mayor de San Marcos, Division of Endocrinology, Hospital Nacional Daniel Alcides Carrion, Lima, Peru
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Clark JL, Rudloff E, Rick M. Percent recovery of insulin from two different concentrations (3 U/250 mL and 45 U/250 mL) of regular insulin solutions prepared for continuous rate infusion. J Vet Emerg Crit Care (San Antonio) 2020; 31:117-120. [PMID: 33135244 DOI: 10.1111/vec.13023] [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: 09/22/2018] [Revised: 02/20/2019] [Accepted: 04/08/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the percent recovery of regular insulin prepared for administration as a continuous rate infusion (CRI) using 2 different concentrations, 3 and 45 U in 250 mL 0.9% saline. DESIGN In vitro experiment SETTING: Privately-owned emergency and referral teaching hospital. ANIMALS None INTERVENTION: Commercial 250 mL 0.9% sodium chloride IV fluid bags were injected with either 3 U (solution bag A) or 45 U (solution bag B) of regular insulin. The insulin concentration was measured in each bag. A fluid administration and extension set were connected to each bag and 50 mL was drained through the IV tubing. The insulin concentration was then measured from samples post washout. MEASUREMENTS AND MAIN RESULTS Comparison of the concentration of insulin injected into the bag and concentration of insulin in the bag showed that there was a 29.7 and 37.3% recovery of insulin from solution bag A and solution bag B, respectively. Comparison of the concentration of insulin injected into the bag and concentration of insulin in the post 50-mL washout samples showed that there was an 11.9 and 30.6% recovery of insulin from bags A and B, respectively. CONCLUSIONS Substantially more insulin was available after a 50-mL washout from solution bag B compared to solution bag A. Insulin binding to the IV bag and fluid administration set is likely the cause of this difference. CLINICAL SIGNIFICANCE Patients receiving lower concentrations of insulin as a CRI, such as might be prescribed for cats and small dogs may require longer time for resolution of hyperglycemia and ketonemia.
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Affiliation(s)
| | | | - Markus Rick
- Veterinary Diagnostic Laboratory, Michigan State University, Lansing, MI
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Malerba E, Alessandrini F, Grossi G, Giunti M, Fracassi F. Efficacy and Safety of Intramuscular Insulin Lispro vs. Continuous Intravenous Regular Insulin for the Treatment of Dogs With Diabetic Ketoacidosis. Front Vet Sci 2020; 7:559008. [PMID: 33195532 PMCID: PMC7596346 DOI: 10.3389/fvets.2020.559008] [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] [Received: 05/04/2020] [Accepted: 09/14/2020] [Indexed: 11/23/2022] Open
Abstract
The use of rapid-acting insulin analogs as routes of administration other than IV has never been described for the treatment of dogs with diabetic ketoacidosis (DKA). This study aims to compare the efficacy and safety of a new protocol based on IM administration of insulin lispro with that of low-dose IV continuous rate infusion of regular insulin in the treatment of canine DKA. Client-owned dogs with naturally occurring DKA were included. Dogs treated with IM insulin lispro (Group L, n = 11) received 0.25 U/kg. The goal was to achieve a drop of at least 10% in blood glucose between 1 h and the next. If this goal was not achieved, the insulin dose was repeated hourly; otherwise, the insulin dose was not repeated up to a maximum of 3 h, after which the insulin dose was repeated anyway. When blood glucose was ≤250 mg/dL, the insulin dose was reduced to 0.125 U/kg IM every 3 h. Cases receiving IV continuous rate infusion of regular insulin (Group R, n = 13) were treated according to a previously published protocol. The median time to resolution of ketosis was significantly shorter in Group L (12 h; range, 4–27 h) compared to Group R (23 h; 10–46 h; P = 0.04). The median times to resolution of acidemia and ketoacidosis were 13 h (4–35 h) and 17.5 h (4–35 h) in Group L, and 22 h (9–80 h) and 23.5 h (10–80 h) in Group R, respectively. These differences were not significant (P = 0.06 and P = 0.09, respectively). The median length of hospitalization did not differ significantly between groups (P = 0.67). There were no differences in the frequency and severity of adverse events (hypoglycemia, hypokaliemia, and hypophosphatemia) between groups. The new protocol based on IM administration of insulin lispro preliminarily appears effective and safe for treatment of canine DKA.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | | | - Giorgio Grossi
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Massimo Giunti
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
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COVID-19 and type 1 diabetes: dealing with the difficult duo. Int J Diabetes Dev Ctries 2020; 40:315-320. [PMID: 32837091 PMCID: PMC7359765 DOI: 10.1007/s13410-020-00846-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/16/2020] [Indexed: 01/08/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) has aroused global health concerns, particularly in relation to diabetes where it has been associated with poorer outcomes. The bulk of the evolving evidence in diabetes and COVID-19 relates to type 2 diabetes (T2D). Since there are a significant number of patients with type 1 diabetes (T1D) with unique concerns and challenges during the ongoing COVID-19 pandemic, we reviewed existing literature, relevant websites, and related guidelines to form this narrative review to help address key questions in this area. Methods We systematically searched the PubMed database up to May 31, 2020, and retrieved all the articles published on T1D and COVID-19. Results We found 18 relevant articles, each of which carried a part of the evidence regarding the risk of contracting COVID-19 in patients with T1D, effect of COVID-19 on development of T1D, outcomes in T1D with COVID-19, and special management issues in T1D in the light of COVID-19. These have been documented in the present review. Conclusion COVID-19 with T1D presents special challenges. While the available evidence does shed some light, we need more evidence to deal with this difficult duo.
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnostic et Prise en Charge de l’Acidose Métabolique Recommandations formalisées d’experts communes Société de réanimation de langue française (SRLF) – Société française de médecine d’urgence (SFMU). ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
L’acidose métabolique est un trouble fréquemment rencontré en médecine d’urgence et en médecine intensive réanimation. La littérature s’étant enrichie de nouvelles données concernant la prise en charge de l’acidose métabolique, la Société de Réanimation de Langue Française (SRLF) et la Société Française de Médecine d’Urgence (SFMU) ont élaboré des recommandations formalisées d’experts selon la méthodologie GRADE. Les champs de la stratégie diagnostique, de l’orientation et de la prise en charge thérapeutique ont été traités et vingt-neuf recommandations ont été formulées : quatre recommandations fortes (Grade 1), dix recommandations faibles (Grade 2) et quinze avis d’experts. Toutes ont obtenu un accord fort. L’application des méthodes d’Henderson-Hasselbalch et de Stewart pour le diagnostic du mécanisme de l’acidose métabolique est discutée et un algorithme diagnostique est proposé. L’utilisation de la cétonémie et des lactatémies veineuse et capillaire est également traitée. L’intérêt du pH, de la lactatémie et de sa cinétique pour l’orientation des patients en pré-hospitalier et aux urgences est envisagé. Enfin, les modalités de l’insulinothérapie au cours de l’acidocétose diabétique, les indications de la perfusion de bicarbonate de sodium et de l’épuration extra-rénale ainsi que les modalités de la ventilation mécanique au cours des acidoses métaboliques sévères sont traitées dans la prise en charge thérapeutique.
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Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract 2019; 155:107797. [PMID: 31344382 DOI: 10.1016/j.diabres.2019.107797] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/21/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
AIMS Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition. METHODS Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines. RESULTS The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult. CONCLUSIONS DKA should only be diagnosed when all three components are present - the 'D', the 'K' and the 'A'. In addition, the definitions used to diagnose DKA should be standardised - in particular for clinical trials.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK; Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care 2019; 9:92. [PMID: 31418093 PMCID: PMC6695455 DOI: 10.1186/s13613-019-0563-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023] Open
Abstract
Metabolic acidosis is a disorder frequently encountered in emergency medicine and intensive care medicine. As literature has been enriched with new data concerning the management of metabolic acidosis, the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence [SFMU]) have developed formalized recommendations from experts using the GRADE methodology. The fields of diagnostic strategy, patient assessment, and referral and therapeutic management were addressed and 29 recommendations were made: 4 recommendations were strong (Grade 1), 10 were weak (Grade 2), and 15 were experts’ opinions. A strong agreement from voting participants was obtained for all recommendations. The application of Henderson–Hasselbalch and Stewart methods for the diagnosis of the metabolic acidosis mechanism is discussed and a diagnostic algorithm is proposed. The use of ketosis and venous and capillary lactatemia is also treated. The value of pH, lactatemia, and its kinetics for the referral of patients in pre-hospital and emergency departments is considered. Finally, the modalities of insulin therapy during diabetic ketoacidosis, the indications for sodium bicarbonate infusion and extra-renal purification as well as the modalities of mechanical ventilation during severe metabolic acidosis are addressed in therapeutic management.
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Affiliation(s)
- Boris Jung
- Département de Médecine Intensive et Réanimation, CHU Montpellier, 34000, Montpellier, France. .,INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.
| | - Mikaël Martinez
- Pôle Urgence, CH du Forez, 42605, Montbrison, France.,Réseau d'urgence Ligérien Ardèche Nord (REULIAN), Centre Hospitalier Le Corbusier, 42700, Firminy, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse-Grace, Avenue Pasteur, 98012, Monaco, France
| | - Michaël Darmon
- Unité de Médecine Intensive et Réanimation, Hôpital Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Avenue Claude-Vellefaux, 75010, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,France Inserm, ECSTRA Team, UMR 1153, Centre d'Epidémiologie et de Biostatistique, CRESS, Biostatistics and Clinical Epidemiology, Sorbonne-Paris-Cité, Paris, France
| | - Kada Klouche
- INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.,Département de Médecine Intensive-Réanimation, CHU Lapeyronie, 371, Avenue Doyen-Gaston-Giraud, 34295, Montpellier, France
| | - Alexandre Lautrette
- Réanimation, Centre Jean-Perrin, CHU de Clermont-Ferrand, 63000, Clermont-Ferrand, France.,LMGE, UMR CNRS 6023, Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Jacques Levraut
- Département de Médecine d'urgence, CHU de Nice, Hôpital Pasteur-II, 30, Avenue de la Voie Romaine, 06000, Nice, France.,UFR de Médecine, Université de Nice Côte d'Azur, Avenue de Vallombrose, 06000, Nice, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris-VI, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Mathieu Oberlin
- Structure des Urgences, Centre Hospitalier de Cahors, 335, Rue Wilson, 46000, Cahors, France
| | - Nicolas Terzi
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Grenoble, Université de Grenoble, Grenoble, France.,Inserm, U1042, Université Grenoble-Alpes, HP2, 38000, Grenoble, France
| | - Damien Viglino
- Service des Urgences Adultes, CS 10217, CHU Grenoble-Alpes, 38043 Grenoble Cedex 09, Grenoble, France.,Inserm U1042, Laboratoire HP2 Hypoxie-Physiopathologies, Université Grenoble-Alpes, Grenoble, France
| | - Youri Yordanov
- Faculté de Médecine, Sorbonne Universités, 75013, Paris, France.,Inserm, U1153, Université Paris-Descartes, 75006, Paris, France.,Service des Urgences, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Pierre-Géraud Claret
- Pôle Anesthésie Réanimation Douleur Urgences, Centre Hospitalier Universitaire de Nîmes, 4, Rue du Professeur-Robert-Debré, 30029, Nîmes, France
| | - Naïke Bigé
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France
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19
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Seddik AA, Bashier A, Alhadari AK, AlAlawi F, Alnour HH, Bin Hussain AA, Frankel A, Railey MJ. Challenges in management of diabetic ketoacidosis in hemodialysis patients, case presentation and review of literature. Diabetes Metab Syndr 2019; 13:2481-2487. [PMID: 31405665 DOI: 10.1016/j.dsx.2019.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/27/2019] [Indexed: 12/28/2022]
Abstract
Chronic kidney disease is associated with accumulation of uremic toxins that increases insulin resistance which will lead to blunted ability to suppress hepatic gluconeogenesis and reduce peripheral utilization of insulin. CKD patients fail to increase insulin secretion in response to insulin resistance because of acidosis, 1,25 vitamin D deficiency, and secondary hyperparathyroidism. Hemodialysis causes further fluctuations in glycemic control due to alterations in insulin secretion, clearance and resistance. DKA is uncommon in hemodialysis patients because of the absence of glycosuria and osmotic diuresis which accounts for most of the fluid and electrolyte losses seen in DKA, anuric patients may be somewhat protected from dehydration and shock, although still subject to hyperkalemia and metabolic acidosis. However, substantial volume loss can still occur due to a prolonged decrease in oral intake or increased insensible water losses related to tachypnoea and fever. There is no current guidelines for the management of diabetic ketoacidosis in anuric hemodialysis patients considering their differences than general population. In this review article we reviewed the literature and came with specific recommendations for management of Ketoacidosis in patients with CKD treated by hemodialysis.
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Affiliation(s)
- Ayman Aly Seddik
- Nephrology Units, Dubai Hospital, Dubai Health Authority, United Arab Emirates
| | - Alaaeldin Bashier
- Endocrine Department, Dubai Hospital, Dubai Health Authority, United Arab Emirates.
| | | | - Fakhryia AlAlawi
- Nephrology Units, Dubai Hospital, Dubai Health Authority, United Arab Emirates
| | - Hind Hassan Alnour
- Nephrology Units, Dubai Hospital, Dubai Health Authority, United Arab Emirates
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20
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Malerba E, Mazzarino M, Del Baldo F, Corradini S, Carotenuto G, Giunti M, Fracassi F. Use of lispro insulin for treatment of diabetic ketoacidosis in cats. J Feline Med Surg 2019; 21:115-123. [PMID: 29513157 PMCID: PMC10814606 DOI: 10.1177/1098612x18761696] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the efficacy and safety of lispro insulin for the treatment of feline diabetic ketoacidosis (DKA). Times to resolution of hyperglycaemia, ketosis and acidosis were compared between cats treated with continuous rate infusion (CRI) of lispro insulin and cats treated with CRI of regular insulin. METHODS Client-owned cats with naturally occurring DKA, newly diagnosed with diabetes mellitus (DM) or already receiving treatment for DM, were included. Diagnosis of DKA involved the presence of at least two clinical signs consistent with DKA (eg, polyuria/polydipsia, anorexia, severe lethargy, vomiting and dehydration), blood glucose (BG) concentration >13.9 mmol/l (>250 mg/dl), blood beta hydroxybutyrate (BHB) concentration >2.5 mmol/l and venous pH <7.3 or bicarbonate <15 mEq/l. Cats were treated with a standard protocol of an intravenous (IV) CRI of regular insulin (group R) or lispro insulin (group L). The time to resolution of DKA was defined as the time interval from when the IV CRI of insulin began until marked hyperglycaemia (BG >13.9 mmol/l [>250 mg/dl]), ketosis (BHB concentration >1 mmol/l) and acidosis (venous pH <7.3 and/or bicarbonate <15 mEq/l) resolved. RESULTS Eighteen DKA cases (nine per group) were enrolled into the study. There were no significant differences in the median time to resolution of three variables (hyperglycaemia, ketosis and acidosis) between the two groups. Two cats in group R developed hypoglycaemia during the CRI of insulin. One cat in group L and three cats in group R developed hypophosphataemia, which required phosphate supplementation. CONCLUSIONS AND RELEVANCE IV CRI of lispro insulin has few side effects and appears to be as effective as IV CRI of regular insulin in the treatment of cats with DKA.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Michela Mazzarino
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Francesca Del Baldo
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Sara Corradini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Gaia Carotenuto
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Massimo Giunti
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
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21
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Islam T, Sherani K, Surani S, Vakil A. Guidelines and controversies in the management of diabetic ketoacidosis – A mini-review. World J Diabetes 2018; 9:226-229. [PMID: 30588284 PMCID: PMC6304293 DOI: 10.4239/wjd.v9.i12.226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/16/2018] [Accepted: 11/16/2018] [Indexed: 02/05/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is a complication seen in patients with both type 1 and type 2 diabetes. Due to its large, growing economic impact with associated morbidity, closer look at proper management is important. Factors involved in appropriate management involves fluid resuscitation, insulin regimen, and electrolyte replacement including types of fluid and insulin treatment. The caveat with generalized protocol is application to special populations such as renal or heart failure patients the sequelae of complications due to pathophysiology of the disease processes. This leads to complications and longer length of stay in the hospital, therefore, possibly increased cost and resource utilization during the hospitalization. This review takes a closer look at current guidelines of DKA management and resource utilization, the drawbacks of current management protocols and the cost associated with it. Therefore, a need for amendment to existing protocol or initiation of a newer guideline that properly manages DKA should incorporate special populations and appropriate regimen of fluid resuscitation, insulin therapy and electrolyte management.
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Affiliation(s)
- Tasnim Islam
- Department of Pulmonary and Critical Care, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Khalid Sherani
- Department of Pulmonary and Critical Care, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Salim Surani
- Department of Pulmonary and Critical Care, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Abhay Vakil
- Department of Pulmonary and Critical Care, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
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22
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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23
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Razavi Z, Maher S, Fredmal J. Comparison of subcutaneous insulin aspart and intravenous regular insulin for the treatment of mild and moderate diabetic ketoacidosis in pediatric patients. Endocrine 2018; 61:267-274. [PMID: 29797212 DOI: 10.1007/s12020-018-1635-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the safety/efficacy of intermittent subcutaneous rapid-acting insulin aspart with the standard low-dose intravenous infusion protocol of regular insulin for treatment of pediatric diabetic-ketoacidosis. METHODS For a prospective randomized-controlled clinical trial on 50 children/adolescents with mild/moderate diabetic-ketoacidosis, the diagnostic criteria for ketoacidosis included: blood glucose level >250 mg/dl, ketonuria>++, venous pH <7.3 and/or bicarbonate <15 mEq/l. DATA COLLECTED age, sex, clinical/laboratory parameters including blood sugar, arterial blood gases, urine ketones, severity of diabetic-ketoacidosis, amount of insulin administered to correct acidosis, time to recover from diabetic-ketoacidosis, number of days of hospitalization, and complications. Patients were randomly assigned to intervention (subcutaneous) and control (intravenous) groups. Controls received 0.05-0.1 unit/kg/hour intravenous regular insulin infusion until resolution of diabetic-ketoacidosis and stayed in the intensive care unit. Interventions received 0.15 unit/kg subcutaneous insulin aspart every two hours and stayed in regular medical ward. RESULTS From 50 children (age 2-17 years), 56% (28) were females, and 48% (24) had established-type I diabetes. Intervention and control groups had similar baseline clinical/laboratory findings. Average age (years) was 8.6 ± 0.8 for intervention and 8.86 ± 0.7 for control group (p = 0.4) with 64% having moderate diabetic-ketoacidosis. The mean total-dose of insulin units needed for treatment of diabetic-ketoacidosis in intervention (subcutaneous insulin aspart) was lower than controls (intravenous regular insulin) (p < 0.001). No mortality/serious events happened. Three diabetic-ketoacidosis recurrences among interventions and one among controls occurred. CONCLUSIONS To manage mild/moderate diabetic-ketoacidosis in children/adolescents, subcutaneous rapid-acting insulin aspart is an alternative to intravenous infusion of regular insulin. Subcutaneous insulin treated moderate DKA with faster recovery/shorter hospital stay.
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Affiliation(s)
- Zahra Razavi
- Associate Professor, Pediatric Endocrinologist, Pediatrics Department, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran.
| | - Saba Maher
- Pediatric Senior Resident, Department of Pediatrics, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Javad Fredmal
- Associate Professor of Biostatistics, Hamedan University of Medical Sciences, Hamedan, Iran
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24
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Affiliation(s)
- D A Pyke
- Diabetic Department, King's College Hospital, London SE5
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25
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Cohen M, Leibovitz N, Shilo S, Zuckerman-Levin N, Shavit I, Shehadeh N. Subcutaneous regular insulin for the treatment of diabetic ketoacidosis in children. Pediatr Diabetes 2017; 18:290-296. [PMID: 27005007 DOI: 10.1111/pedi.12380] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 02/19/2016] [Accepted: 02/24/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) treatment protocols vary, however low-dose intravenous administration of regular insulin is the standard care for replacing insulin in most centers. Few studies, the majority in adults, demonstrated subcutaneous injection of rapid-acting insulin every 1-2 hours to be a valid alternative. OBJECTIVE To evaluate the efficacy and safety of subcutaneous regular insulin administered every 4 hours in pediatric DKA in a clinical setting. METHODS A retrospective chart review was conducted. Charts of all children treated with subcutaneous regular insulin for DKA and pH ≥ 7.0, between 2007 and 2010, were reviewed. Seventy-six DKA episodes in 52 patients were included. Data regarding clinical characteristics, response to treatment, and the occurrence of complications were analyzed. DKA episodes in patients with new-onset diabetes and in those with established diabetes were compared. RESULTS Mean age was 11.6 ± 4.0 yr. Eighteen episodes occurred in children with new-onset diabetes. In all episodes, our protocol resulted in recovery from DKA. Median time to DKA resolution (pH > 7.30, HCO3 > 15) was 10.3 (5.5, 14.2) h. The median total insulin dose was 0.05 (0.04, 0.06) (unit/kg/h). During DKA treatment, hypoglycemia occurred in one episode and hypokalemia, mostly mild, was documented in 14. No cardiac arrhythmias, incidents of cerebral edema, or mortality occurred. CONCLUSION Subcutaneous regular insulin administered every 4 hours is an effective and safe alternative for the insulin treatment of DKA with pH > 7.0 in children. Such treatment has the potential to simplify insulin administration when compared to either intravenous regular insulin or q1-2 hour subcutaneous rapid insulin and reduce both patient inconvenience and admission costs.
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Affiliation(s)
- Michal Cohen
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel
| | - Noa Leibovitz
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Smadar Shilo
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel
| | - Nehama Zuckerman-Levin
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Itai Shavit
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Naim Shehadeh
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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26
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Dhatariya KK, Vellanki P. Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA). Curr Diab Rep 2017; 17:33. [PMID: 28364357 PMCID: PMC5375966 DOI: 10.1007/s11892-017-0857-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries. RECENT FINDINGS Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
- University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
| | - Priyathama Vellanki
- Division of Endo, Metabolism & Lipids, Emory University School of Medicine, Atlanta, GA, USA
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Cardoso L, Vicente N, Rodrigues D, Gomes L, Carrilho F. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism 2017; 68:43-54. [PMID: 28183452 DOI: 10.1016/j.metabol.2016.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 01/22/2023]
Abstract
Hyperglycaemic emergencies are associated with significant morbi-mortality and healthcare costs. Management consists on fluid replacement, insulin therapy, and electrolyte correction. However, some areas of patient management remain debatable. In patients without respiratory failure or haemodynamic instability, arterial and venous pH and bicarbonate measurements are comparable. Fluid choice varies upon replenishment phase and patient's condition. If patient is severely hypovolaemic, normal saline solution should be the first option. However, if patient has mild/moderate dehydration, fluid choice must take in consideration sodium concentration. Insulin therapy should be guided by β-hydroxybutyrate normalization and not by blood glucose. Variations of conventional insulin infusion protocols emerged recently. Priming dose of insulin may not be required, and fixed rate insulin infusion represents the best option to suppress hepatic glucose production, ketogenesis, and lipolysis. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycaemia. Simpler protocols using subcutaneous rapid-acting insulin analogues for mild/moderate diabetic ketoacidosis treatment have proven to be safe and effective, but further studies are required to confirm these results. Treatment with bicarbonate, phosphate, and low-molecular-weight heparin is still disputable, and randomized controlled trials are urgently needed to optimize patient management and decrease the morbi-mortality of hyperglycaemic emergencies.
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Affiliation(s)
- Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Nuno Vicente
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dírcea Rodrigues
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Leonor Gomes
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Francisco Carrilho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Basetty S, Yeshvanth Kumar GS, Shalini M, Angeline RP, David KV, Abraham S. Management of diabetic ketosis and ketoacidosis with intramuscular regular insulin in a low-resource family medicine setting. J Family Med Prim Care 2017; 6:25-28. [PMID: 29026743 PMCID: PMC5629894 DOI: 10.4103/2249-4863.214992] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: India is facing an epidemic of diabetes mellitus (DM). Effective management of complications of DM is a challenge in resource-poor areas of India. This study addresses the need to explore low-cost methods to manage diabetic ketosis (DK) and diabetic ketoacidosis (DKA). Objectives: To demonstrate the use of intramuscular (IM) regular insulin as a safe alternative method to control DK and DKA in a family practice setting. Materials and Methods: A retrospective chart review was done for 34 patients admitted with DK and DKA in a family medicine unit for the urban poor over 5 years. Data on age, sex, precipitating factors, blood pressure, number of days of hospitalization, amount of insulin, and time required to control blood glucose (BG) and to correct acidosis were entered into EpiData version 3.1 and analyzed using SPSS software version 17. Results: Administration of IM regular insulin was effective in reducing the BG to < 250 mg/dL in patients with DK and DKA. The mean time required for this in the ketosis group was 3.8 h and in the ketoacidosis group was 3.9 h. The mean amount of insulin required for correction of acidosis in the ketoacidosis group was 72.3 units and the mean time to achieve this was 33 h. Of the 34 patients, only one in the ketoacidosis group had hypoglycemia. There was no fatality or referral of any patient. Conclusion: This study demonstrates that IM regular insulin is a safe alternative method in managing DK and DKA in a family medicine setting.
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Affiliation(s)
- Sudhakar Basetty
- Department of Family Medicine, Low Cost Effective Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - G S Yeshvanth Kumar
- Department of Family Medicine, Low Cost Effective Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Martina Shalini
- Community Health and Development, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ruby Pricilla Angeline
- Department of Family Medicine, Low Cost Effective Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kirubah Vasandhi David
- Department of Family Medicine, Low Cost Effective Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sunil Abraham
- Department of Family Medicine, Low Cost Effective Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
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Schmeisl GW, Kretzschmar Y. [Fast-acting insulin - new developments towards more flexibility for the patient]. MMW Fortschr Med 2016; 158:5-11. [PMID: 27933575 DOI: 10.1007/s15006-016-9053-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/08/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Post-prandial insulin secretion occurs under physiological conditions very fast and in adequate concentrations. This mechanism is impaired in patients with type 2 diabetes and severe increases of postprandial glucose levels may occur. In order to achieve physiological conditions and to avoid postprandial hyperglycemia, exogenous insulin and insulin analogues should be absorbed very fast and appropriate maximum concentrations should be reached very quickly. METHOD Overview RESULTS AND CONCLUSIONS: The development of new bolus insulins is focused on improved pharmacokinetic and pharmacodynamic properties. Not only new pharmaceutical formulations, but also different application sites and systems have been investigated. The latest innovations resulted in even faster acting insulins, which may offer patients improved postprandial glucose control and greater flexibility regarding meal planning.
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Affiliation(s)
- Gerhard W Schmeisl
- Medizin/Angiologie/Rehabilitationswesen/Sportmedizin/Diabetologe DDG/Sozialmedizin, Deegenbergklinik und Saale Klinik ( DRV-Bund), Bad Kissingen, Deutschland.
- Facharzt für Innere Medizin / Angiologie / Rehabilitationswesen / Sportmedizin / Diabetologe DDG / Sozialmedizin Deegenbergklinik, Burgstraße, 97688, Bad Kissingen, Deutschland.
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Helfer EL, Schorr AB, Miller JL, Rose LI. Control of Hyperglycemia with Hyperalimentation Solutions Containing Insulin. J Pharm Technol 2016. [DOI: 10.1177/875512258800400504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Martin C, McKinney ZJ, Hoody D, Fish L. DIABETIC KETOACIDOSIS CRITICAL CARE PATHWAY IMPLEMENTATION: INCORPORATION INTO EMR SIGNIFICANTLY DECREASES LENGTH OF STAY. Endocr Pract 2016; 22:673-8. [PMID: 27176140 DOI: 10.4158/ep151073.or] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We discuss the implementation and outcomes of a diabetic ketoacidosis (DKA) critical care pathway (CCP) at a 462-bed teaching hospital. METHODS A multi-disciplinary team implemented a DKA CCP that was translated into 3 computerized physician order entry (CPOE) order sets corresponding to the phases of DKA care. Historical and postintervention data were obtained via automated queries of the electronic medical record (EMR) and further analyzed by manual chart review. RESULTS Average length of stay decreased from 104.3 to 72.9 hours (P = .0003) after implementation of a DKA CCP. CONCLUSION Outcome data supports the use of a DKA CCP at our institution. ABBREVIATIONS DKA = diabetic ketoacidosis CCP = critical care pathway EMR = electronic medical record CPOE = computerized physician order entry ICD-9 = International Classification of Diseases, ninth revision LoS = length of stay SQL = standard query language.
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Andrade‐Castellanos CA, Colunga‐Lozano LE, Delgado‐Figueroa N, Gonzalez‐Padilla DA. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database Syst Rev 2016; 2016:CD011281. [PMID: 26798030 PMCID: PMC8829395 DOI: 10.1002/14651858.cd011281.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Carlos A Andrade‐Castellanos
- Hospital Civil de Guadalajara "Dr. Juan I. Menchaca"Department of Emergency MedicineSalvador Quevedo y Zubieta No. 750GuadalajaraJaliscoMexico44340
| | - Luis Enrique Colunga‐Lozano
- Hospital Civil de Guadalajara "Fray Antonio Alcalde"Department of Critical Care MedicineCalle Coronel Calderón #777GuadalajaraGuadalajaraMexico44320
| | - Netzahualpilli Delgado‐Figueroa
- Hospital Civil de Guadalajara Dr. Juan I. MenchacaDepartment of PediatricsSalvador Quevedo y Zubieta No. 750GuadalajaraJaliscoMexico44340
| | - Daniel A Gonzalez‐Padilla
- Hospital Universitario 12 de OctubreDepartment of UrologyAvenida de Córdoba, s/nMadridMadridSpain28041
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Ma J, Zhou H, Xu H, Chen X, Teng X, Liu Q, Liu W. The Initial Assessment of Daily Insulin Dose in Chinese Newly Diagnosed Type 2 Diabetes. J Diabetes Res 2016; 2016:7245947. [PMID: 26697503 PMCID: PMC4678086 DOI: 10.1155/2016/7245947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 05/27/2015] [Accepted: 05/27/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND It has been well accepted that insulin therapy is the ideal treatment for newly diagnosed diabetic patients. However, there was no study about assessment of the initial insulin dosage in new onset Chinese patients with type 2 diabetes. RESEARCH DESIGN AND METHODS 65 newly diagnosed patients with type 2 diabetes (39 males/26 females; HbA1c ≥ 11.80 ± 0.22%) were investigated. All patients had random hyperglycaemia (at 21.8 ± 3.9 mmol/L) on the first day of admission and received insulin infusion intravenously (5 U/per hour). When the blood glucose level dropped to around 10 mmol/L, patients were then transferred to continuous subcutaneous insulin infusion (CSII). The reduction of blood glucose levels in response to per unit of insulin (RBG/RI) was recorded. The target glucose level was achieved in about 3 days. The total daily insulin dose (TDD) and basal insulin dose (TBD) were calculated. RESULTS TDD was 45.97 ± 1.28 units and TBD was 19.00 ± 0.54 units. TBD was about 40% of the total daily insulin requirement. There was a negative correlation between the ratio of RBG/RI and TDD. CONCLUSIONS TDD was correlated with blood glucose reduction in response to intravenous insulin infusion in Chinese new onset patients with type 2 diabetes.
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Affiliation(s)
- Jing Ma
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai 200127, China
| | - Huan Zhou
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai 200127, China
| | - Hua Xu
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai 200127, China
| | - Xie Chen
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai 200127, China
| | - Xiangyu Teng
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai 200127, China
| | - Qianjing Liu
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai 200127, China
| | - Wei Liu
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai 200127, China
- *Wei Liu:
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Ayed S, Bouguerba A, Ahmed P, Barchazs J, Boukari M, Goldgran-Toledano D, Bornstain C, Vincent F. Les pièges de l’acidocétose diabétique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1113-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Desse TA, Eshetie TC, Gudina EK. Predictors and treatment outcome of hyperglycemic emergencies at Jimma University Specialized Hospital, southwest Ethiopia. BMC Res Notes 2015; 8:553. [PMID: 26455633 PMCID: PMC4601134 DOI: 10.1186/s13104-015-1495-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 09/21/2015] [Indexed: 12/11/2022] Open
Abstract
Background Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) commonly known as hyperglycemic emergencies are the two most common life-threatening acute metabolic complications of diabetes. The objective of this study is to assess predictors and treatment outcome of hyperglycemic emergencies (HEs) among diabetic patients admitted to Jimma University Specialized Hospital (JUSH). Methods It is a three year retrospective review of medical records of patients admitted with HEs at JUSH. Patient demographics, admission clinical characteristics, precipitants, insulin used and treatment outcomes were extracted. Statistical analysis was done using student’s t test, Chi square test, and binary logistic regression with level of α set at 0.05. Statistical significance was considered for variables with p < 0.05. Results Complete data was available for 163 out of 421 patients admitted with HEs. The majority (62.6 %) were males. Mean age of patients was 36.6 ± 15.9 years. About 64 % of patients had type 1 diabetes. About 93 % of the participants developed DKA. The most common precipitants of HEs were infections 95 (59 %), non-compliance to medications 52 (32.3 %), and newly diagnosed diabetes 38 (23.6 %). Recurrent hyperglycemia, hypoglycemia and ketonuria occurred in 88 (54 %), 34 (20.9 %) and 31 (20.5 %) patients respectively. Mean amount of insulin used and duration of treatment till resolution of DKA were 136.85 ± 152.41 units and 64.38 ± 76.34 h respectively. The median length of hospital stay was 6 days. Mortality from HEs was 16 (9.8 %). Admission serum creatinine >1.2 mg/dL (P = 0.018), co-morbidity (P < 0.001) and sepsis (P = 0.014) were independent predictors of HEs mortality. Conclusions Infections, non-compliance and new onset diabetes were the most common precipitants of HEs. Length of hospital stay and mortality were high. High use of insulin, recurrent hyperglycemia, hypoglycemia, and ketonuria were common during HEs management. Elevated serum creatinine, sepsis and co-morbidity are independent predictors of HEs mortality.
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Affiliation(s)
- Tigestu Alemu Desse
- Clinical Pharmacy Department, School of Pharmacy, Jimma University, Jimma, Ethiopia.
| | | | - Esayas Kebede Gudina
- Departments of Internal Medicine, School of Medicine, Jimma University, Jimma, Ethiopia.
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Cohn BG, Keim SM, Watkins JW, Camargo CA. Does Management of Diabetic Ketoacidosis with Subcutaneous Rapid-acting Insulin Reduce the Need for Intensive Care Unit Admission? J Emerg Med 2015; 49:530-8. [PMID: 26238182 DOI: 10.1016/j.jemermed.2015.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/21/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND In the last 20 years, rapid-acting insulin analogs have emerged on the market, including aspart and lispro, which may be efficacious in the management of diabetic ketoacidosis (DKA) when administered by non-intravenous (i.v.) routes. CLINICAL QUESTION In patients with mild-to-moderate DKA without another reason for intensive care unit (ICU) admission, is the administration of a subcutaneous (s.c.) rapid-acting insulin analog a safe and effective alternative to a continuous infusion of i.v. regular insulin, and would such a strategy eliminate the need for ICU admission? EVIDENCE REVIEW Five randomized controlled trials were identified and critically appraised. RESULTS The outcomes suggest that there is no difference in the duration of therapy required to resolve DKA with either strategy. CONCLUSION Current evidence supports DKA management with s.c. rapid-acting insulin analogs in a non-ICU setting in carefully selected patients.
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Affiliation(s)
- Brian G Cohn
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Samuel M Keim
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, Arizona
| | - Joseph W Watkins
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Carlos A Camargo
- Departments of Emergency Medicine and Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
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Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care 2014; 37:3124-31. [PMID: 25342831 PMCID: PMC4207202 DOI: 10.2337/dc14-0984] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The hyperosmolar hyperglycemic state (HHS) is the most serious acute hyperglycemic emergency in patients with type 2 diabetes. von Frerichs and Dreschfeld described the first cases of HHS in the 1880s in patients with an "unusual diabetic coma" characterized by severe hyperglycemia and glycosuria in the absence of Kussmaul breathing, with a fruity breath odor or positive acetone test in the urine. Current diagnostic HHS criteria include a plasma glucose level >600 mg/dL and increased effective plasma osmolality >320 mOsm/kg in the absence of ketoacidosis. The incidence of HHS is estimated to be <1% of hospital admissions of patients with diabetes. The reported mortality is between 10 and 20%, which is about 10 times higher than the mortality rate in patients with diabetic ketoacidosis (DKA). Despite the severity of this condition, no prospective, randomized studies have determined best treatment strategies in patients with HHS, and its management has largely been extrapolated from studies of patients with DKA. There are many unresolved questions that need to be addressed in prospective clinical trials regarding the pathogenesis and treatment of pediatric and adult patients with HHS.
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Affiliation(s)
- Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Affiliation(s)
- Stuart J Brink
- New England Diabetes and Endocrinology Center (NEDEC), Waltham, MA, USA, and Associate Clinical Professor of Pediatrics; Tufts University School of Medicine; Boston MA USA
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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Jivan D. Management of diabetic ketoacidosis. JOURNAL OF ENDOCRINOLOGY METABOLISM AND DIABETES OF SOUTH AFRICA 2014. [DOI: 10.1080/22201009.2011.10872247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- D Jivan
- Department of Medicine, Division of Endocrinology and Metabolism, University of the Witwatersrand
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Abstract
Diabetic ketoacidosis (DKA) is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Elements of management include making the appropriate diagnosis using current laboratory tools and clinical criteria and coordinating fluid resuscitation, insulin therapy, and electrolyte replacement through feedback obtained from timely patient monitoring and knowledge of resolution criteria. In addition, awareness of special populations such as patients with renal disease presenting with DKA is important. During the DKA therapy, complications may arise and appropriate strategies to prevent these complications are required. DKA prevention strategies including patient and provider education are important. This review aims to provide a brief overview of DKA from its pathophysiology to clinical presentation with in depth focus on up-to-date therapeutic management.
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Affiliation(s)
- Aidar R Gosmanov
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, TN, USA
- Correspondence: Aidar R Gosmanov, Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN 38163, USA, Fax +1 901 448 5940, Email
| | - Elvira O Gosmanova
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Erika Dillard-Cannon
- Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Memphis, TN, USA
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Miyares MA, Zlicha A, Rodriguez JN. Development and implementation of a hyperglycemic emergency protocol. Am J Health Syst Pharm 2013; 70:1567, 1572, 1574, 1577. [DOI: 10.2146/ajhp120782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Marta A. Miyares
- Pharmacy Department Jackson Memorial Hospital 1611 N.W. 12 Avenue East Tower B069 Miami, FL 33136
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Vincent M, Nobécourt E. Treatment of diabetic ketoacidosis with subcutaneous insulin lispro: a review of the current evidence from clinical studies. DIABETES & METABOLISM 2013; 39:299-305. [PMID: 23642642 DOI: 10.1016/j.diabet.2012.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/05/2012] [Accepted: 12/10/2012] [Indexed: 12/23/2022]
Abstract
AIM Low-dose intravenous infusions of regular insulin, usually initiated in the emergency department and continued in the intensive care unit (ICU), are the standard care for patients with diabetic ketoacidosis (DKA) to ensure rapid resolution of hyperglycaemia and ketoacidosis. Several studies have evaluated whether subcutaneous injections of the rapid-acting analogue insulin lispro may be an alternative to intravenous insulin infusion for avoiding ICU admissions of uncomplicated DKA cases. METHODS This review summarizes the current clinical evidence for the effectiveness and safety of subcutaneous insulin lispro injections in non-severe DKA patients. Relevant studies were identified by a systematic literature search through the PubMed database. RESULTS To date, four small randomized studies (156 patients overall; three studies in adults and one in paediatric patients with diabetes) have directly compared subcutaneous insulin lispro injections every 1-2h vs continuous intravenous infusions of regular insulin. Patients with severe complications were excluded. In all studies, the mean time to resolution of DKA was similar in both treatment groups [range (three studies): lispro 10-14.8h; regular insulin 11-13.2h]. The mean time to resolution of hyperglycaemia, total insulin doses required, number of hospitalization days and number of hypoglycaemic episodes were similar in both treatment groups; no severe complications or DKA recurrences were reported, and one study showed a 39% cost reduction for the insulin lispro group. CONCLUSION In patients with mild-to-moderate DKA, subcutaneous injections of insulin lispro every 1-2h offer a feasible alternative to continuous intravenous infusions of regular insulin, and should now be evaluated in larger, more appropriately powered studies.
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Affiliation(s)
- M Vincent
- Medical - Diabetes, Lilly France, Suresnes, France
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Barski L, Kezerle L, Zeller L, Zektser M, Jotkowitz A. New approaches to the use of insulin in patients with diabetic ketoacidosis. Eur J Intern Med 2013; 24:213-6. [PMID: 23395363 DOI: 10.1016/j.ejim.2013.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/10/2013] [Accepted: 01/11/2013] [Indexed: 10/27/2022]
Abstract
Diabetic ketoacidosis (DKA) is one of the most common and serious acute complications of diabetes and is a significant cause of morbidity and mortality. In the last decade the mortality rate from DKA has declined because of greater recognition and improvements in its management. The current available guidelines state that the most effective means of insulin delivery during DKA is a continuous infusion of regular insulin, usually referred to as continuous low-dose insulin infusion. However, the cost of this treatment is usually quite high, because patients are required to be admitted to an intensive care unit in order to be monitored closely. New analogs of human insulin that have a rapid onset of action have become available in the past decade and represent potential alternatives to the use of regular insulin in the treatment of DKA. In several trials it has been demonstrated that the use of subcutaneous rapid-acting insulin analogs represents a safe, cost-effective and technically simpler treatment that precludes intensive care unit admission without significant differences in outcome in the management of patients with mild to moderate, uncomplicated DKA. The long-acting insulin analog may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA. This avoids rebound hyperglycaemia and ketogenesis when intravenous insulin is stopped and may avoid excess length of stay.
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Affiliation(s)
- Leonid Barski
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel.
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Ford W, Self WH, Slovis C, McNaughton CD. Diabetes in the Emergency Department and Hospital: Acute Care of Diabetes Patients. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013; 1:1-9. [PMID: 23997994 PMCID: PMC3756609 DOI: 10.1007/s40138-012-0007-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- William Ford
- Candace D. McNaughton, MD, is an Assistant Professor, Wesley H. Self, MD, is an Assistant Professor, and Corey Slovis, MD, is the Chairman of Emergency Medicine in the Department of Emergency Medicine at Vanderbilt University Medical Center in Nashville, Tennessee, USA
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Udwadia F, Bhattacharyya A, Seshiah V, Kumar Sethi B, Kumar S, Kumar Subbanna P, Shetty R, Moses A. Intravenous insulin aspart in a hospital setting: results from an observational study examining patient outcomes and physician preferences. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/dmt.12.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Nyenwe EA, Kitabchi AE. Evidence-based management of hyperglycemic emergencies in diabetes mellitus. Diabetes Res Clin Pract 2011; 94:340-51. [PMID: 21978840 DOI: 10.1016/j.diabres.2011.09.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 09/02/2011] [Accepted: 09/12/2011] [Indexed: 11/26/2022]
Abstract
The hyperglycemic emergencies, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially fatal complications of uncontrolled diabetes mellitus. The incidence of DKA and the economic burden of its treatment continue to rise, but its associated mortality rate which was uniformly high has diminished remarkably over the years. This Improvement in outcome is largely due to better understanding of the pathogenesis of hyperglycemic emergencies and the application of evidence-based guidelines in the treatment of patients. In this article, we present a critical review of the evidence behind the recommendations that have resulted in the improved prognosis of patients with hyperglycemic crises. A succinct discussion of the pathophysiology and important etiological factors in DKA and HHS are provided as a prerequisite for understanding the rationale for the effective therapeutic maneuvers employed in these acute severe metabolic conditions. The evidence for the role of preventive measures in DKA and HHS is also discussed. The unanswered questions and future research needs are also highlighted.
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Affiliation(s)
- Ebenezer A Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Devi R, Selvakumar G, Clark L, Downer C, Braithwaite SS. A dose-defining insulin algorithm for attainment and maintenance of glycemic targets during therapy of hyperglycemic crises. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/dmt.11.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.
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