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Fry K, Ryman K, Abdelmonem A, Wang X, Vassaur J, Kataria V. Success of Insulin Infusion Transitions in Moderate to Severe Diabetic Ketoacidosis With Transition Anion Gap of Less Than or Equal to 12 mEq/L Versus Greater Than 12 mEq/L. Hosp Pharm 2024; 59:334-340. [PMID: 38764987 PMCID: PMC11097940 DOI: 10.1177/00185787231218935] [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: 05/21/2024]
Abstract
Background: Patients with diabetic ketoacidosis (DKA) are transitioned from intravenous (IV) to subcutaneous (SQ) insulin upon DKA resolution. Although an anion gap (AG) ≤12 mEq/L is recommended before transition to SQ insulin, there are limited data to support this threshold. Objective: To compare the rates of successful transitions to SQ insulin in patients with DKA with an AG ≤ 12 mEq/L versus > 12 mEq/L. Methods: Retrospective cohort study of adult critically ill patients with moderate to severe DKA between September 2019 and December 2022. The primary outcome was the success of insulin transition between patients transitioned with an AG ≤ 12 mEq/L and those transitioned with an AG > 12 mEq/L. Transition was considered successful if the AG did not increase above the value at transition at 24 hours and insulin infusion was not restarted. Secondary outcomes include the individual components of the primary outcome and ICU length of stay (LOS); safety outcomes included hypoglycemia and electrolyte derangements. Results: In total, 92 patients were included, with 43 patients transitioned at AG ≤ 12 mEq/L and 49 patients transitioned at AG > 12 mEq/L. Transition was unsuccessful in 3 patients (7%) with AG ≤ 12 mEq/L and 2 patients (4%) with AG > 12 mEq/L (P = .66). There was no difference in the incidence of the individual components of this outcome between groups or in safety outcomes. Conclusion: This retrospective study showed no difference in success of insulin transition between the groups. Larger studies are needed to evaluate the impact of treatment characteristics on transition success and patient outcomes.
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Affiliation(s)
- Kjersti Fry
- Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Xuan Wang
- Baylor Research Institute, Dallas, TX, USA
| | - John Vassaur
- Baylor University Medical Center, Dallas, TX, USA
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2
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Haak T, Gölz S, Fritsche A, Füchtenbusch M, Siegmund T, Schnellbächer E, Klein HH, Uebel T, Droßel D. Therapy for Type 1 Diabetes. Exp Clin Endocrinol Diabetes 2024; 132:125-135. [PMID: 38365208 DOI: 10.1055/a-2166-6695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
- Thomas Haak
- Diabetes Centre Bad Mergentheim, Bad Mergentheim, Germany
| | | | - Andreas Fritsche
- Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
| | | | | | | | - Harald H Klein
- Department of Internal Medicine I - General Internal Medicine, Endocrinology and Diabetology, Gastroenterology and Hepatology, Bergmannsheil University Hospitals, Bochum, Germany
| | - Til Uebel
- prima-diab Practice Drs. Uebel/Nittka/Mayer/Merkle, Ittlingen, Germany
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3
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Gant P, Barfield D, Florey J. Comparison of insulin infusion protocols for management of canine and feline diabetic ketoacidosis. J Vet Emerg Crit Care (San Antonio) 2024; 34:23-30. [PMID: 37987148 DOI: 10.1111/vec.13354] [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: 12/30/2021] [Revised: 09/12/2022] [Accepted: 10/06/2022] [Indexed: 11/22/2023]
Abstract
OBJECTIVE Describe the use of fixed-rate intravenous insulin infusions (FRIs) in cats and dogs with diabetic ketoacidosis (DKA) and determine if this is associated with faster resolution of ketosis compared to variable-rate intravenous insulin infusions (VRIs). Secondary objectives were to evaluate complication rates, length of hospitalization (LOH), and survival to discharge (STD). DESIGN Randomized clinical trial (January 2019 to July 2020). SETTING University veterinary teaching hospital and private referral hospital. ANIMALS Dogs and cats with DKA and venous pH <7.3, blood glucose concentration >11 mmol/L (198 mg/dL), and β-hydroxybutyrate (BHB) concentration >3 mmol/L were eligible for inclusion. Patients were randomly assigned to receive either FRI or VRI. INTERVENTIONS Neutral (regular) insulin was administered IV as an FRI or VRI. For FRI, the rate was maintained at 0.01 IU/kg/h. For VRI, the dose was adjusted according to blood glucose concentration. MEASUREMENTS AND RESULTS Sixteen cats and 20 dogs were enrolled. Population characteristics, mean insulin infusion rate, time to resolution of ketosis (BHB <0.6 mmol/L), complications, LOH, and STD were evaluated. In cats, overall resolution of ketosis was low (9/16 [56.3%]), limiting comparison of protocols. In dogs, resolution of ketosis was high (19/20 dogs [95.0%]) but the time to resolution in the FRI group was not different than that in the VRI group (P = 0.89), despite a 25% higher average insulin infusion rate in the FRI group (P = 0.04). The incidence of complications was low and did not differ between protocols. In cats, LOH and STD did not differ between protocols. All cats that died (5/16) did so within 78 hours and none had resolution of ketosis. Dogs receiving FRI had a shorter LOH (P = 0.01) but STD did not differ between protocols. Six dogs (30.0%) did not survive to hospital discharge but all had resolution of ketosis. CONCLUSIONS FRIs can be used in veterinary species but may not hasten resolution of ketosis.
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Affiliation(s)
- Poppy Gant
- Department of Emergency and Critical Care, Willows Referral Service, Solihull, UK
| | - Dominic Barfield
- Section of Emergency and Critical Care, Department of Clinical Science and Services, Royal Veterinary College, London, UK
| | - Jessica Florey
- Department of Internal Medicine, Dick White Referrals, Cambridgeshire, UK
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4
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Gilchrist HE, Hatton CJ, Roginski MA, Esteves AM. Impact on Diabetic Ketoacidosis Resolution After Implementation of a 2-Bag Fluid Order Set. Ann Pharmacother 2023; 57:1361-1366. [PMID: 37021360 DOI: 10.1177/10600280231163838] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a serious acute complication of both type 1 and type 2 diabetes that requires prompt management. Limited data exist supporting the use of a 2-bag DKA protocol in adult patients across all levels of care. OBJECTIVE To evaluate the efficacy and safety of a 2-bag DKA protocol in comparison with a traditional DKA management strategy. METHODS Retrospective review of patients admitted with DKA between January 1, 2021, and February 28, 2022, at a single center. Patients were separated into 2 cohorts, traditional or 2-bag. The primary outcome was time to anion gap closure and/or beta-hydroxybutyrate normalization. Secondary outcomes include length of hospitalization, insulin infusion time, and hypoglycemic events. RESULTS One hundred forty-three patients had a DKA order set initiated during their admission, 59 in the traditional cohort and 84 in the 2-bag cohort. Mean time to anion gap closure was shorter in the 2-bag cohort (12.7 vs 16.9 hours; P = 0.005) and beta-hydroxybutyrate normalization (15.6 vs 25.6 hours; P = 0.026). No difference in hospital length of stay (4 vs 6 days; P = 0.113), duration of insulin infusion (41.6 vs 40.6 hours; P = 0.455), or rates of hypoglycemia (6 vs 4; P = 0.872) was seen. CONCLUSION AND RELEVANCE Implementation of a 2-bag DKA protocol in the inpatient setting was associated with a shorter time to anion gap closure and beta-hydroxybutyrate normalization. These findings support the option of expansion of a 2-bag DKA protocol to adult patients across all levels of care irrespective of the admission diagnosis.
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Affiliation(s)
- Hannah E Gilchrist
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Colman J Hatton
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Matthew A Roginski
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Alyson M Esteves
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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5
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Shaka H, DeHart L, El-amir Z, Wani F, Ramirez M, Kichloo A. Rising Readmission Rates After Diabetic Ketoacidosis Hospitalization Among Adults With Type 1 Diabetes Throughout a Decade in the United States. Clin Diabetes 2023; 41:220-225. [PMID: 37092155 PMCID: PMC10115619 DOI: 10.2337/cd22-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Research on longitudinal trends in readmission rates after diabetic ketoacidosis (DKA) is lacking. This retrospective study was aimed at identifying trends in readmissions after hospitalization for DKA, as well as trends in outcomes after readmission, over time among adults with type 1 diabetes in the United States. Findings indicate that the DKA readmission rate increased from 53 to 73 events per 100,000 between 2010 to 2018, and low-income and uninsured patients had higher odds of readmission. There was no significant change in mortality after readmission over time. Improved access to care and affordable management options may play a crucial role in preventing readmissions.
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Affiliation(s)
- Hafeez Shaka
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luke DeHart
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI
| | - Zain El-amir
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI
| | - Farah Wani
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI
| | - Marcelo Ramirez
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI
- Department of Medicine, Samaritan Medical Center, Watertown, NY
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6
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Khan AA, Ata F, Iqbal P, Bashir M, Kartha A. Clinical and biochemical predictors of intensive care unit admission among patients with diabetic ketoacidosis. World J Diabetes 2023; 14:271-278. [PMID: 37035234 PMCID: PMC10075029 DOI: 10.4239/wjd.v14.i3.271] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 02/14/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) contributes to 94% of diabetes-related hospital admissions, and its incidence is rising. Due to the complexity of its management and the need for rigorous monitoring, many DKA patients are managed in the intensive care unit (ICU). However, studies comparing DKA patients managed in ICU to non-ICU settings show an increase in healthcare costs without significantly affecting patient outcomes. It is, therefore, essential to identify suitable candidates for ICU care in DKA patients.
AIM To evaluate factors that predict the requirement for ICU care in DKA patients.
METHODS This retrospective study included consecutive patients with index DKA episodes who presented to the emergency department of four general hospitals of Hamad Medical Corporation, Doha, Qatar, between January 2015 and March 2021. All adult patients (> 14 years) fulfilling the American Diabetes Association criteria for DKA diagnosis were included.
RESULTS We included 922 patients with DKA in the final analysis, of which 229 (25%) were managed in the ICU. Compared to non-ICU patients, patients admitted to ICU were older [mean (SD) age of 40.4 ± 13.7 years vs 34.5 ± 14.6 years; P < 0.001], had a higher body mass index [median (IQR) of 24.6 (21.5-28.4) kg/m2 vs 23.7 (20.3-27.9) kg/m2; P < 0.030], had T2DM (61.6%) and were predominantly males (69% vs 31%; P < 0.020). ICU patients had a higher white blood cell count [median (IQR) of 15.1 (10.2-21.2) × 103/uL vs 11.2 (7.9-15.7) × 103/uL, P < 0.001], urea [median (IQR) of 6.5 (4.6-10.3) mmol/L vs 5.6 (4.0-8.0) mmol/L; P < 0.001], creatinine [median (IQR) of 99 (75-144) mmol/L vs 82 (63-144) mmol/L; P < 0.001], C-reactive protein [median (IQR) of 27 (9-83) mg/L vs 14 (5-33) mg/L; P < 0.001] and anion gap [median (IQR) of 24.0 (19.2-29.0) mEq/L vs 22 (17-27) mEq/L; P < 0.001]; while a lower venous pH [mean (SD) of 7.10 ± 0.15 vs 7.20 ± 0.13; P < 0.001] and bicarbonate level [mean (SD) of 9.2 ± 4.1 mmol/L vs 11.6 ± 4.3 mmol/L; P < 0.001] at admission than those not requiring ICU management of DKA (P < 0.001). Patients in the ICU group had a longer LOS [median (IQR) of 4.2 (2.7-7.1) d vs 2.0 (1.0-3.9) d; P < 0.001] and DKA duration [median (IQR) of 24 (13-37) h vs 15 (19-24) h, P < 0.001] than those not requiring ICU admission. In the multivariate logistic regression analysis model, age, Asian ethnicity, concurrent coronavirus disease 2019 (COVID-19) infection, DKA severity, DKA trigger, and NSTEMI were the main predicting factors for ICU admission.
CONCLUSION In the largest tertiary center in Qatar, 25% of all DKA patients required ICU admission. Older age, T2DM, newly onset DM, an infectious trigger of DKA, moderate-severe DKA, concurrent NSTEMI, and COVID-19 infection are some factors that predict ICU requirement in a DKA patient.
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Affiliation(s)
- Adeel Ahmad Khan
- Department of Endocrinology, Hamad Medical Corporation, Doha 00000, Qatar
| | - Fateen Ata
- Department of Endocrinology, Hamad Medical Corporation, Doha 00000, Qatar
| | - Phool Iqbal
- Department of Medicine, Metropolitan Hospital Center, New York, NY 10595, United States
| | - Mohammed Bashir
- Department of Endocrinology, Hamad Medical Corporation, Doha 00000, Qatar
| | - Anand Kartha
- Department of Medicine, Hamad Medical Corporation, Doha 00000, Qatar
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7
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Eledrisi MS, Alkabbani H, Aboawon M, Ali A, Alabdulrazzak I, Elhaj M, Ahmed A, Alqahwachi H, Daghfal J, Beshyah SA, Malik RA. Clinical characteristics and outcomes of care in patients hospitalized with diabetic ketoacidosis. Diabetes Res Clin Pract 2022; 192:110041. [PMID: 35985426 DOI: 10.1016/j.diabres.2022.110041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/25/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022]
Abstract
AIMS To assess the clinical characteristics and outcomes of patients hospitalized with DKA. METHODS We examined the hospital database for patients admitted with DKA to all government hospitals in Qatar over 6 years. RESULTS We evaluated a total of 1330 patients [(37.3 % with type 1 diabetes (T1DM) and 62.7 % with type 2 diabetes (T2DM)] with 1613 episodes of DKA. Patients with T2DM were older than those with T1DM [48.0 (38.0-60.0), 26.0 (21.0-31.0) years] while there was no difference in DKA severity and laboratory values on admission or time to resolution of DKA. Admission to the intensive care unit was higher (38.9 % vs. 26.6 %; P < 0.001) with a longer hospital stay [5 (2.0-9.0) vs. 2 (2.0-4.0) days, P < 0.001] and markedly higher mortality (7.4 % vs. 1 %; P < 0.001) in patients with T2DM compared to T1DM. On multivariable logistic regression analysis, significant predictors of mortality were older age (odds ratio, 1.11; 95 % CI, 1.07-1.15; P = 0.0001), and admission to the intensive care unit (odds ratio, 3.61; 95 % CI, 1.69-7.72;P = 0.001). CONCLUSION In this national cohort of patients hospitalized with DKA, those with T2DM had a 7-fold increase in inpatient mortality associated with older age and admission to the intensive care unit.
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Affiliation(s)
- Mohsen S Eledrisi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar; Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Haifaa Alkabbani
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Malk Aboawon
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Aya Ali
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Maab Elhaj
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Ashraf Ahmed
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Joanne Daghfal
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Salem A Beshyah
- Department of Endocrinology, Yas Clinic, Abu Dhabi, United Arab Emirates; Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Rayaz A Malik
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar; Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar; Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, United Kingdom
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Haak T, Gölz S, Fritsche A, Füchtenbusch M, Siegmund T, Schnellbächer E, Klein HH, Uebel T, Droßel D. Therapy of Type 1 Diabetes. Exp Clin Endocrinol Diabetes 2022; 130:S39-S48. [PMID: 35373309 DOI: 10.1055/a-1624-3340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | | | - Andreas Fritsche
- Department of Internal Medicine IV, University Hospital, Tübingen, Germany
| | | | - Thorsten Siegmund
- Diabetes, Hormones and Metabolism Centre, Private Practice at the Isar Hospital, Munich, Germany
| | | | - Harald H Klein
- Department of Endocrinology and Diabetes, Medical Hospital I, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
| | - Til Uebel
- prima-diab Practice Dres. Uebel, Ittlingen, Germany
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9
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Zheng DJ, Iskander S, Vujcic B, Amin K, Valani R, Yan JW. A comparison of adult diabetic ketoacidosis treatment protocols from Canadian emergency departments. Can J Diabetes 2021; 46:269-276.e2. [DOI: 10.1016/j.jcjd.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/05/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
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10
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Anis TR, Boudreau M, Thornton T. Comparing the Efficacy of a Nurse-Driven and a Physician-Driven Diabetic Ketoacidosis (DKA) Treatment Protocol. Clin Pharmacol 2021; 13:197-202. [PMID: 34675693 PMCID: PMC8504870 DOI: 10.2147/cpaa.s334119] [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: 08/20/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Standardized DKA treatment could result in better overall safety and efficacy outcomes. The primary objective of this study is to validate the efficacy of an adapted nurse-driven DKA protocol compared to a physician-driven DKA protocol across the continuum of three hospital settings: the University of Colorado upon which the physician-driven protocol is based, Northern Light Eastern Maine Medical Center (NLEMMC), and Northern Light Sebasticook Valley Hospital (NLSVH). The secondary objective is to assess the safety of the adapted nurse-driven DKA protocol adapted at NLEMMC and NLSVH through determining the incidence of hypoglycemia and anion gap reopening. Patients and Methods This was a retrospective, IRB-approved, multi-center study that included: patients 18 years or older who were treated with the DKA protocol at NLEMMC or NLSVH, and admitted to the emergency department between July 2015 and October 2020 with a primary diagnosis of DKA and an elevated anion gap greater than or equal to 13 mEq/L. Results A total of 90 patients from NLEMMC and 64 patients from NLSVH were included and compared to 111 patients from the University of Colorado who were included in the post protocol implementation group. There was no statistically significant difference in the primary outcome, time to anion gap closure, between the original University of Colorado study (10.3 hours) and the NLEMMC (10.9 hours, p = 0.420) and NLSVH (8.8 hours, p = 0.115) results presented in this study. Conclusion The standardized nurse-driven DKA treatment protocol at NLEMMC and NLSVH showed no statistical difference in time to anion gap closure compared to the University of Colorado study upon which it was based. This finding is particularly relevant to hospitals such as NLEMMC and NLSVH that lack provider resources and teams of endocrinologists required for the physician-driven DKA protocol.
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Affiliation(s)
- Takla R Anis
- Pharmacy Department, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Marybeth Boudreau
- Pharmacy Department, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Tyson Thornton
- Pharmacy Department, Northern Light Sebasticook Valley Hospital, Pittsfield, ME, USA
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11
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Haak T, Gölz S, Fritsche A, Füchtenbusch M, Siegmund T, Schnellbächer E, Klein HH, Uebel T, Droßel D. Therapie des Typ-1-Diabetes – Kurzfassung der S3-Leitlinie (AWMF-Registernummer: 057-013; 2. Auflage). DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1515-8682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | | | - Andreas Fritsche
- Innere Medizin IV, Medizinische Klinik, Universitätsklinikum Tübingen
| | | | | | | | - Harald H. Klein
- Medizinische Universitätsklinik I – Allgemeine Innere Medizin, Endokrinologie und Diabetologie, Gastroenterologie und Hepatologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
| | - Til Uebel
- prima-diab Praxis Dres. Uebel/Nittka/Mayer/Merkle, Ittlingen
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12
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Everett EM, Copeland TP, Moin T, Wisk LE. National Trends in Pediatric Admissions for Diabetic Ketoacidosis, 2006-2016. J Clin Endocrinol Metab 2021; 106:2343-2354. [PMID: 33942077 PMCID: PMC8277205 DOI: 10.1210/clinem/dgab287] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Diabetic ketoacidosis (DKA) rates in the United States are rising. Prior studies suggest higher rates in younger populations, but no studies have evaluated national trends in pediatric populations and differences by subgroups. As such, we sought to examine national trends in pediatric DKA. METHODS We used the 2006, 2009, 2012, and 2016 Kids' Inpatient Database to identify pediatric DKA admissions among a nationally representative sample of admissions of youth ≤20 years old. We estimate DKA admission per 10 000 admissions and per 10 000 population, charges, length of stay (LOS), and trends over time among all hospitalizations and by demographic subgroups. Regression models were used to evaluate differences in DKA rates within subgroups overtime. RESULTS Between 2006 and 2016, there were 149 535 admissions for DKA. Unadjusted DKA rate per admission increased from 120.5 (95% CI, 115.9-125.2) in 2006 to 217.7 (95% CI, 208.3-227.5) in 2016. The mean charge per admission increased from $14 548 (95% CI, $13 971-$15 125) in 2006 to $20 997 (95% CI, $19 973-$22 022) in 2016, whereas mean LOS decreased from 2.51 (95% CI, 2.45-2.57) to 2.28 (95% CI, 2.23-2.33) days. Higher DKA rates occurred among 18- to 20-year-old females, Black youth, without private insurance, with lower incomes, and from nonurban areas. Young adults, men, those without private insurance, and from nonurban areas had greater increases in DKA rates across time. CONCLUSIONS Pediatric DKA admissions have risen by 40% in the United States and vulnerable subgroups remain at highest risk. Further studies should characterize the challenges experienced by these groups to inform interventions to mitigate their DKA risk and to address the rising DKA rates nationally.
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Affiliation(s)
- Estelle M Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Correspondence: Estelle Everett, MD, MHS, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon Ste 850, Los Angeles, CA 90024, United States.
| | - Timothy P Copeland
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Tannaz Moin
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Lauren E Wisk
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Mertens M, Dauben L, Roden M, Müssig K. [Acute metabolic complications in diabetes]. Dtsch Med Wochenschr 2021; 146:266-278. [PMID: 33592663 DOI: 10.1055/a-1270-8878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Over time, diabetes patients are at increased risk for microvascular and macrovascular complications leading to increased morbidity and mortality compared to metabolically healthy people. In addition, acute life-threatening metabolic derangements at first manifestation as well as during the course of the disease may occur, comprising diabetic ketoacidosis, hyperosmolar hyperglycaemic state and hypoglycaemia. Diabetes-related emergencies require fast diagnosis and early treatment initiation as well as close monitoring of vital signs and laboratory parameters. The present article gives an overview on the acute metabolic complications in diabetes, focussing on diagnostic work-up and treatment goals.
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14
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Impact of a Nurse-Driven Diabetic Ketoacidosis Insulin Infusion Calculator on the Rate of Hypoglycemia. J Patient Saf 2020; 16:e255-e259. [PMID: 33215892 DOI: 10.1097/pts.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the impact of an insulin infusion calculator incorporated into electronic health record system in reducing the rate of hypoglycemia in diabetic ketoacidosis (DKA) management. METHODS Retrospective chart review of patients with primary admission diagnosis of DKA was conducted in a university-affiliated academic medical center. End points including the rate of hypoglycemia, time to DKA resolution, rate of hypokalemia, time on insulin drip, and length of stay were measure before and after implementation of DKA calculator. RESULTS Of 181 adult patients admitted for primary diagnosis of DKA, 103 were managed using the calculator. After implementation of the calculator, incidence of hypoglycemia and severe hypoglycemia were significantly reduced by 70% and 87%, respectively (P < 0.01). No difference was observed for time to DKA resolution, time on insulin drip, and length of stay. CONCLUSIONS Implementation of DKA insulin infusion calculator significantly reduced the rate of hypoglycemia. Future improvements should focus on reducing time to DKA resolution and length of stay.
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Haak T, Gölz S, Fritsche A, Füchtenbusch M, Siegmund T, Schnellbächer E, Klein HH, Uebel T, Droßel D. Therapie des Typ-1-Diabetes – Kurzfassung der S3-Leitlinie (AWMF-Registernummer: 057-013; 2. Auflage). DIABETOL STOFFWECHS 2020. [DOI: 10.1055/a-1193-3724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | | | - Andreas Fritsche
- Innere Medizin IV, Medizinische Klinik, Universitätsklinikum Tübingen
| | | | | | | | - Harald H. Klein
- Medizinische Universitätsklinik I – Allgemeine Innere Medizin, Endokrinologie und Diabetologie, Gastroenterologie und Hepatologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
| | - Til Uebel
- prima-diab Praxis Dres. Uebel/Nittka/Mayer/Merkle, Ittlingen
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Broberg MCG, Rose JA, Slain KN. The Relationship Between Estimated Median Household Income and Critical Care Length of Stay in Children With Diabetic Ketoacidosis. Glob Pediatr Health 2020; 7:2333794X20956770. [PMID: 32974415 PMCID: PMC7495926 DOI: 10.1177/2333794x20956770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/09/2020] [Accepted: 08/17/2020] [Indexed: 11/17/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is an important diagnosis in the pediatric intensive care unit (PICU) and is associated with significant morbidity. We hypothesized children with DKA living in poorer communities would have unfavorable outcomes while critically ill. This single-center retrospective study included children with DKA admitted to a PICU over a 27-month period. Patients were classified as low-income if they lived in a ZIP code where the median household income was estimated to be less than 200% of the federal poverty threshold, or $48 016 for a family of 4. In this study, living in a low-income ZIP code was not associated with increased severity of illness, longer PICU length of stay (LOS), or readmission.
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Affiliation(s)
- Meredith C. G. Broberg
- University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jerri A. Rose
- University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katherine N. Slain
- University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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The Association of ICU Acuity With Adherence to ICU Evidence-Based Processes of Care. Chest 2020; 158:579-587. [PMID: 32229228 DOI: 10.1016/j.chest.2020.02.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/23/2020] [Accepted: 02/15/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Admission to high-acuity ICUs has been associated with improved outcomes compared with outcomes in low-acuity ICUs, although the mechanism for these findings is unclear. RESEARCH QUESTION The goal of this study was to determine if high-acuity ICUs more effectively implement evidence-based processes of care that have been associated with improved clinical outcomes. STUDY DESIGN AND METHODS This retrospective cohort study was performed in adult ICU patients admitted to 322 ICUs in 199 hospitals in the Philips ICU telemedicine database between 2010 and 2015. The primary exposure was ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. Multivariable logistic regression was used to examine relations of ICU acuity with adherence to evidence-based VTE and stress ulcer prophylaxis, and with the avoidance of potentially harmful events. These events included hypoglycemia, sustained hyperglycemia, and liberal transfusion practices (defined as RBC transfusions prescribed for nonbleeding patients with preceding hemoglobin levels ≥ 7 g/dL). RESULTS Among 1,058,510 ICU admissions, adherence to VTE and stress ulcer prophylaxis was high across acuity levels. In adjusted analyses, those admitted to low-acuity ICUs compared with the highest acuity ICUs were more likely to experience hypoglycemic events (adjusted OR [aOR], 1.12; 95% CI, 1.04-1.19), sustained hyperglycemia (aOR, 1.07; 95% CI, 1.04-1.10), and liberal transfusion practices (aOR, 1.55; 95% CI, 1.33-1.82). INTERPRETATION High-acuity ICUs were associated with better adherence to several evidence-based practices, which may be a marker of high-quality care. Future research should investigate how high-acuity ICUs approach ICU organization to identify targets for improving the quality of critical care across all ICU acuity levels.
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Moderate-Intensity Insulin Therapy Is Associated With Reduced Length of Stay in Critically Ill Patients With Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State. Crit Care Med 2020; 47:700-705. [PMID: 30855284 DOI: 10.1097/ccm.0000000000003709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Insulin infusion therapy is commonly used in the hospital setting to manage diabetic ketoacidosis and hyperosmolar hyperglycemic state. Clinical evidence suggests both hypoglycemia and glycemic variability negatively impact patient outcomes. The hypothesis of this study was that moderate-intensity insulin therapy decreases hospital length of stay and prevalence of hypoglycemia in patients with diabetic ketoacidosis and hyperosmolar hyperglycemic state. DESIGN Pre-post study. SETTING Large academic medical center in the United States. PATIENTS Two-hundred one consecutive, nonpregnant, adult patients admitted for diabetic ketoacidosis and hyperosmolar hyperglycemic state between October 2010 and December 2014. INTERVENTIONS High-intensity insulin therapy versus moderate-intensity insulin therapy. High-intensity insulin therapy was designed to rapidly normalize blood glucose levels with bolus doses of insulin and rapid insulin titration. Moderate-intensity insulin therapy was designed to mitigate glycemic variability and hypoglycemia through avoidance of bolus dosing, a liberalized blood glucose target, and gradual insulin titration. MEASUREMENTS AND MAIN RESULTS Hospital and ICU length of stay were reduced by 23.6% and 38%, respectively. The relative risk of remaining in the hospital at day 7 (0.51; p = 0.022) and day 14 (0.28; p = 0.044) were significantly reduced by the moderate-intensity insulin therapy strategy. The relative risk of remaining in the ICU at 48 hours was significantly lower in the moderate-intensity insulin therapy cohort (0.34; p = 0.0048). The prevalence (35% vs 1%; p = 0.0003) and relative risk (0.028; p = 0.0004) of hypoglycemia were significantly lower in the moderate-intensity insulin therapy cohort. Glycemic variability decreased by 28.6% (p < 0.0001). There was no difference in the time to anion gap closure (p = 0.123). CONCLUSIONS Moderate-intensity insulin therapy for diabetic ketoacidosis and hyperosmolar hyperglycemic state resulted in improvements in hospital and ICU length of stay, which appeared to be associated with decreased glycemic variability.
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Reducing Diabetic Ketoacidosis Intensive Care Unit Admissions Through an Electronic Health Record-Driven, Standardized Care Pathway. J Healthc Qual 2020; 42:e66-e74. [DOI: 10.1097/jhq.0000000000000247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Haas NL, Whitmore SP, Cranford JA, Tsuchida RE, Nicholson A, Boyd C, Gunnerson KJ, Gianchandani RY, Bassin BS. An Emergency Department-Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis. J Emerg Med 2019; 58:620-626. [PMID: 31843318 DOI: 10.1016/j.jemermed.2019.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/27/2019] [Accepted: 10/13/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED. OBJECTIVE We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA. METHODS This was a retrospective pre-post cohort of ED visits from 2012-2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed. RESULTS We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat [NNT] = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ. CONCLUSION Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.
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Affiliation(s)
| | | | | | | | | | - Caryn Boyd
- University of Michigan, Ann Arbor, Michigan
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Lawrence SE. The Use of Clinical Pathways and Order Sets in the Management of Diabetic Ketoacidosis. Can J Diabetes 2019; 43:295-296. [DOI: 10.1016/j.jcjd.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mohamed M, Assal A, Boyle L, Kwok E, DeSousa F, Karovitch A, Malcolm J. Development and Implementation of a Diabetic Ketoacidosis Protocol for Adults With Type 1 and Type 2 Diabetes at a Tertiary Care Multicampus Hospital. Can J Diabetes 2019; 43:256-260.e3. [DOI: 10.1016/j.jcjd.2018.08.192] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023]
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Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ 2019; 365:l1114. [PMID: 31142480 DOI: 10.1136/bmj.l1114] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.
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Affiliation(s)
- Esra Karslioglu French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amy C Donihi
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mary T Korytkowski
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Defayette AA, Voigt LM, Zammit KT, Nadler JN, Kersten BP. Evaluation of a Computerized Insulin Dosing Tool for the Treatment of Diabetic Ketoacidosis. J Pharm Pract 2019; 33:768-773. [PMID: 30852934 DOI: 10.1177/0897190019834367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Computerized insulin dosing tools (CIDT) have been shown to improve the care of critically ill patients with hyperglycemia. Application of a CIDT in addition to a diabetic ketoacidosis (DKA) order set for the treatment of DKA has not been evaluated. Our goal was to determine the effects the CIDT would have on the treatment of a patient with DKA. METHODS In this retrospective, pre-post chart review, a provider-driven insulin dosing strategy (pregroup) was compared to the CIDT (postgroup) with 24-hour pharmacist monitoring. The CIDT utilized an equation that incorporated a patient's most recent blood glucose (BG) value and recommended a rate of insulin (units/hour) every hour. RESULTS All baseline characterizes were similar between the 2 groups. There were no significant differences in average time to anion gap closure (≤ 12 mEq/L) or intensive care unit length of stay between the pregroup and postgroup (12.5 [6] hours vs 10.5 [7] hours, P = 0.235; 40.6 [24] hours vs 40.8 [24] hours, P = 0.945). Although not statistically significant, 17 hypoglycemic events (BG < 70 mg/dL) occurred in the pregroup with 4 being severe (BG < 50 mg/dL) while 5 hypoglycemic events occurred in the postgroup, none of which were severe. CONCLUSION This study suggests, when compared to a provider-driven insulin dosing strategy, the CIDT with 24-hour pharmacist monitoring is efficacious and safe for treatment of patients with a primary diagnosis of DKA.
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Affiliation(s)
| | - Lisa M Voigt
- Kaleida Health, Buffalo General Medical Center, Buffalo, New York, USA
| | - Kimberly T Zammit
- Kaleida Health, Buffalo General Medical Center, Buffalo, New York, USA
| | - Jamie N Nadler
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Brian P Kersten
- Kaleida Health, Buffalo General Medical Center, Buffalo, New York, USA
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Karajgikar ND, Manroa P, Acharya R, Codario RA, Reider JA, Donihi AC, Salata RA, Korytkowski MT. ADDRESSING PITFALLS IN MANAGEMENT OF DIABETIC KETOACIDOSIS WITH A STANDARDIZED PROTOCOL. Endocr Pract 2019; 25:407-412. [PMID: 30657360 DOI: 10.4158/ep-2018-0398] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective: To determine the efficacy and safety of a diabetic ketoacidosis (DKA)-Power Plan (PP) for guiding intravenous (IV) insulin infusions prior to anion gap (AG) closure and administering subcutaneous (SC) insulin ≥1 hour before discontinuing IV insulin. Methods: Retrospective chart review of patients with DKA before (pre-PP) (n = 60) and following (post-PP) (n = 60) implementation of a DKA-PP. Groups were compared for percentage of patients for whom IV insulin therapy was continued until AG closure, the percentage of patients receiving SC insulin ≥1 hour before discontinuation of IV insulin, and percentage of patients with rebound DKA during the index hospitalization. Results: Admission plasma glucose (514 mg/dL vs. 500 mg/dL; P = .36) and venous pH (7.2 vs. 7.2; P = .57) were similar in pre- and post-PP groups. Inappropriate discontinuation of IV insulin occurred less frequently in post-PP patients (28% vs. 7%; P = .007), with a lower frequency of rebound DKA (40% vs. 8%; P = .001) following acute management. More post-PP patients received SC insulin ≥1 hour before discontinuation of IV insulin (65% vs. 78%; P = .05). Conclusion: Implementation of a DKA-PP was associated with appropriate discontinuation of IV insulin in more patients, more frequent administration of SC insulin ≥1 hour prior to discontinuation of IV insulin, and fewer episodes of rebound DKA. Abbreviations: ADA = American Diabetes Association; AG = anion gap; BG = blood glucose; DKA = diabetic ketoacidosis; DKA-PP = DKA-Power Plan; ICU = intensive care unit; IQR = interquartile range; IV = intravenous; IVF = IV fluid; LOS = length of stay; SC = subcutaneous.
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Noll KM, Franck AJ, Hendrickson AL, Telford ED, Maltese Dietrich N. Integration of Around-the-Clock Clinical Pharmacy Specialists Into the Critical Care Team Can Increase Safety of Hyperglycemic Crisis Management. Clin Diabetes 2019; 37:86-89. [PMID: 30705502 PMCID: PMC6336124 DOI: 10.2337/cd18-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve the safety of hyperglycemic crisis management at a Veterans Affairs Medical Center by making clinical pharmacy specialists available to the critical care team 24 hours/day.
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Affiliation(s)
- Krista M Noll
- North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - Andrew J Franck
- North Florida/South Georgia Veterans Health System, Gainesville, FL
| | | | - Evan D Telford
- North Florida/South Georgia Veterans Health System, Gainesville, FL
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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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Clark A, Kraut E, Yen HH, Moore S, Hopman W, Houlden RL. Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit. Can J Diabetes 2018; 43:304-308.e3. [PMID: 30713091 DOI: 10.1016/j.jcjd.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess safety and efficacy compared to a historical cohort. Clinical practice guidelines recommend that patients with diabetic ketoacidosis (DKA) be treated with a standardized protocol. We created a multifaceted order set to promote best-practice management of DKA. METHODS We performed a retrospective cohort study of admissions to internal medicine for DKA in adults during a 4.5-year period; 2.25 years before and after order-set initiation. Groups were compared using independent samples t tests and Pearson chi-square or Fisher exact test (categorical data). The Mann-Whitney U test was used for continuous data not normally distributed. RESULTS The order-set cohort consisted of 47 admissions, 72.3% with type 1 and 27.7% with type 2 diabetes. The historical cohort consisted of 59 admissions, 69.5% with type 1 and 30.5% with type 2 diabetes. There were no significant differences in initial laboratory values between patients with type 1 and type 2 diabetes in both cohorts. The median length of hospital stay approached significance in the order-set cohort: 3.53 days (2.5 to 5.1); in the historical cohort, the median length of stay was 4.6 days (2.44 to 8.99) (p=0.102). CONCLUSION A standardized DKA order set was as effective and safe in type 1 and type 2 diabetes as individual physician management in an academic care setting. Further study is needed to assess its value in community hospital settings with less expertise and fewer diabetes specialty services.
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Affiliation(s)
- Alexa Clark
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Eyal Kraut
- Division of Endocrinology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hope H Yen
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah Moore
- School of Nursing (PhD candidate), Queen's University, Kingston, Ontario, Canada
| | - Wilma Hopman
- Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Robyn L Houlden
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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Alkhiari R, Alzayer H, Aljazeeri J, Vanniyasingam T, Punthakee Z. Adherence to Guidelines for Inpatient Pharmacologic Management of Type 2 Diabetes in Adults and Glycemic Outcomes. Can J Diabetes 2018; 42:158-162. [DOI: 10.1016/j.jcjd.2017.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 05/08/2017] [Accepted: 05/10/2017] [Indexed: 12/01/2022]
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Hamelin AL, Yan JW, Stiell IG. Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State in Adults: National Survey of Attitudes and Practice. Can J Diabetes 2017; 42:229-236. [PMID: 28734951 DOI: 10.1016/j.jcjd.2017.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES In 2013, the Canadian Diabetes Association, now Diabetes Canada, published national clinical practice guidelines for the effective management of diabetic ketoacidosis and hyperosmolar hyperglycemic states in adults. We sought to determine emergency physician compliance rates and attitudes toward these guidelines and to identify potential barriers to their use in Canadian emergency departments. METHODS An online survey consisting of questions related to the awareness and use of the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada was distributed to 500 randomly selected members of the Canadian Association of Emergency Physicians. Also included in the survey were 3 clinical vignettes to assess adherence rates to the guidelines. RESULTS The survey response rate was 62.2% (311 of 500). The majority of physicians reported the guidelines to be useful (83.6%); 54.6% of respondents were familiar with the guidelines, and 54.7% claimed to use them in clinical practice. The most frequently reported barrier to guideline implementation was a lack of education (56.0%). The clinical vignettes demonstrated respondent variability in fluid administration and sodium bicarbonate administration, as well as some variability in insulin and potassium administration. CONCLUSIONS Although Canadian emergency physicians were generally supportive of the guidelines, many were unaware that these guidelines existed, and barriers to their implementation were reported. These results suggest the need to improve knowledge translation strategies across Canadian emergency departments to standardize management of diabetic ketoacidosis and hyperosmolar hyperglycemic states and support the highest quality of patient care, as well as to ensure that future guidelines include management strategies applicable to the emergency department setting.
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Affiliation(s)
| | - Justin W Yan
- The Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian G Stiell
- The University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Tran TTT, Pease A, Wood AJ, Zajac JD, Mårtensson J, Bellomo R, Ekinci EI. Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols. Front Endocrinol (Lausanne) 2017; 8:106. [PMID: 28659865 PMCID: PMC5468371 DOI: 10.3389/fendo.2017.00106] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/02/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs). OBJECTIVE To review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes. METHODS Ovid Medline searches were conducted with limits "all adult" and published between "1973 to current" applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers' assessment of title, abstract, and availability. RESULTS A total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over "sliding scale" insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1-2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes. CONCLUSION There are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.
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Affiliation(s)
- Tara T. T. Tran
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Anthony Pease
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Anna J. Wood
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Jeffrey D. Zajac
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Elif I. Ekinci
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
- Menzies School of Health Research, Darwin, NT, Australia
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Rohrbach EF, Webb K, Costello T. Comparison of Two Intravenous Insulin Titration Methods in Hyperglycemic Crisis. J Pharm Technol 2017. [DOI: 10.1177/8755122517690749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Glycemic control using intravenous insulin infusions is an important component of hyperglycemic crisis treatment. Literature supports the use of standardized titration protocols; however, comparisons of specific methods are limited. Objective: Compare the safety and efficacy of 2 insulin infusion titration methods used in hyperglycemic crisis. Methods: A retrospective chart review was conducted including adults admitted to an inpatient facility from August 1, 2013, to August 1, 2015, who were treated for at least 4 hours with an intravenous insulin infusion. Primary efficacy outcomes of time to anion gap closure and time to goal blood glucose was studied in patients meeting criteria for diabetic ketoacidosis (n = 79), while the primary safety outcome of rates of hypoglycemia were compared among all study patients (n = 200). Results: The fixed-rate titration method had statistically shorter time to blood glucose <200 mg/dL compared to the multiplier titration group (6.1 [4.0] vs 8.8 [4.4], respectively; P = .018; mean time in hours [standard deviation]); however, no statistically significant difference was seen in the other primary efficacy and safety outcomes. Statistical improvements were found in secondary outcomes of intensive/progressive care units, length of stay, and infusion duration in the fixed-rate titration method, while less deviation from titration recommendations was found in the multiplier titration group. Conclusions: Significant differences seen in time to a goal blood glucose, deviation prevalence, and holds of the infusion for low blood glucose have identified areas for optimization, additional study, and staff education.
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Affiliation(s)
| | | | - Tracy Costello
- Community Health Network, Indianapolis, IN, USA
- Butler University, Indianapolis, IN, USA
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Laliberte B, Yeung SYA, Gonzales JP. Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2017; 25:238-243. [PMID: 28338247 DOI: 10.1111/ijpp.12346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 12/15/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the rate of compliance to the 2006 and 2009 ADA DKA guidelines in the medical intensive care unit (MICU) at a large academic medical centre after the implementation of a computerised DKA order set and protocol. METHODS Retrospective chart review of adult patients with DKA admitted to the MICU. Results of pre-order set (PRE) were compared to those of data post-order set (POST). The primary outcome was a composite administration of intravenous fluid resuscitation in the first 24 h, insulin bolus and initial insulin infusion rate. KEY FINDINGS Twelve of 60 patients (20%) in the PRE group received treatment compliant with the 2006 guidelines versus 14 of 55 patients (25.5%) in the POST group (OR 1.22 95% CI 0.44 to 3.4, P = 0.51). Compliance to the 2009 guidelines was significantly higher in the POST group (31.7% versus 65.5%, OR 4.44 95% CI 1.8 to 10.92, P = 0.0004). Compliance for individual components was 26.7% versus 70.9% for fluid resuscitation (P = 0.0001), 55% versus 49.1% for insulin bolus (P = 0.58) and 60% versus 81.3% for initial insulin infusion rate (P = 0.014), respectively. Time to DKA resolution was decreased (P = 0.04), and hypoglycaemia was increased (P = 0.0022). CONCLUSION Implementation of a computerised DKA order set and protocol was associated with improved compliance to the 2009 ADA DKA guidelines, 24-h fluid resuscitation, initial insulin infusion rate, time to DKA resolution and appropriate transition to subcutaneous insulin. However, patients in the POST implementation group were more likely to exhibit hypoglycaemia. Future assessment is warranted.
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Affiliation(s)
| | - Siu Yan Amy Yeung
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jeffrey P Gonzales
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Al Nemri A, Amer YS, Gasim H, Osman ME, Aleyadhy A, Al Otaibi H, Iqbal SM, Aljurayyan NA, Assiri AM, Babiker A, Mohamed S. Substantial reduction in hospital stay of children and adolescents with diabetic ketoacidosis after implementation of Clinical Practice Guidelines in a university hospital in Saudi Arabia. J Eval Clin Pract 2017; 23:173-177. [PMID: 27896902 DOI: 10.1111/jep.12661] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 10/05/2016] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES We aimed to determine the effect of Clinical Practice Guideline (CPG) implementation on length of hospital stay of children and adolescents with diabetic ketoacidosis (DKA). METHODS This was a 6-year (2008-2014) case-control retrospective study conducted at King Khalid University Hospital, Riyadh, that compared patients with DKA managed using CPG with those treated before CPG implementation. RESULTS There were 63 episodes of DKA in 41 patients managed using CPG compared with 40 episodes in 33 patients treated before implementation of CPG. Baseline characteristics of the 2 groups were similar (age, sex, newly diagnosed patients, recurrent DKA, DKA severity, and mean glycosylated hemoglobin). The mean length of hospital stay (±SD) was 68.6 ± 53.1 hours after implementation of CPG compared with 107.4 ± 65.6 hours before implementation (P < .001). The reduction in length of hospital stay equals to 1700 bed days saved per year per 1000 patients. CONCLUSIONS Implementation of CPG for DKA decreased the length of hospital stay.
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Affiliation(s)
- Abdulrahman Al Nemri
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yasser Sami Amer
- Quality Management, King Khalid University Hospital, Riyadh, Saudi Arabia.,CPGs Steering Committee, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hala Gasim
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed Elfaki Osman
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Aleyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hessah Al Otaibi
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Shaikh Mohammed Iqbal
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Asaad M Assiri
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah bin Khalid Coeliac Disease Research Chair, King Saud University College of Medicine, Riyadh, Saudi Arabia
| | - Amir Babiker
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Pediatrics, National Guard Hospital, Riyadh, Saudi Arabia
| | - Sarar Mohamed
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Fusco N, Gonzales J, Yeung SYA. Evaluation of the treatment of diabetic ketoacidosis in the medical intensive care unit. Am J Health Syst Pharm 2016; 72:S177-82. [PMID: 26582306 DOI: 10.2146/sp150028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To determine if treatment of DKA in a sample of adult medical intensive care unit (MICU) patients was consistent with the 2006 ADA Hyperglycemic Crises in Adult Patients with Diabetes Clinical Guidelines. METHODS Medical records were reviewed for all adult patients admitted to a MICU with a diagnosis of DKA between July 1, 2007 and June 30, 2010. The primary composite endpoint assessed fluid resuscitation (total mL/kg) at 24 hours, insulin bolus dose, and continuous insulin infusion (units/kg or units/kg/hour) to determine whether the 2006 ADA clinical guidelines for Hyperglycemic Crises in Adult Patients with Diabetes were followed. Secondary outcome measures were DKA resolution, ICU length of stay, frequency of rebound DKA within 48 hours, frequency of hypoglycemia, and time to transition to subcutaneous insulin. RESULTS A total of 60 patients met inclusion criteria. For patients treated in compliance with the clinical guidelines compared to those that were not, total volume IV fluid infused during the first 24 hours (4.88 ± 0.77 mL/kg/hour and 2.74 ± 1.08 mL/kg/hour), mean dose of the insulin bolus (0.13 ± 0.04 units/kg and 0.06 ± 0.06 units/kg) and initial rate of the insulin infusions (0.11 ± 0.02 units/kg/hour and 0.08 ± 0.03 units/kg/hour) were significantly different (p <0.001). Treatment of 12 patients (20%) followed the 2006 ADA clinical guidelines, and mean time to resolution of DKA and MICU length of stay trended toward a shorter duration in these patients. CONCLUSION Compliance with the 2006 ADA Hyperglycemic Crises in Adult Patients with Diabetes clinical guidelines was low for treatment of DKA in a sample of adult patients admitted to a MICU. Institutional guidelines for the management of diabetic ketoacidosis should be investigated as a strategy to improve compliance with national guidelines.
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Affiliation(s)
- Nicholas Fusco
- PGY-1 Pharmacy Practice Resident, Department of Pharmacy, University of Maryland Medical Center
| | - Jeffrey Gonzales
- Assistant Professor, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy
| | - Siu Yan Amy Yeung
- Critical Care Specialist, Department of Pharmacy, University of Maryland Medical Center
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Suleiman AK. A prospective study assessing the etiology of Diabetes mellitus among Jordanian patients. Diabetes Metab Syndr 2016; 10:S60-S63. [PMID: 26878988 DOI: 10.1016/j.dsx.2016.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/09/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diabetes mellitus has considerable public health implications for communities, individuals, and health services. Increasing prevalence of diabetes all over the world intensifies the demand for health care services, and particularly for inpatient care. AIM The present study aims to assess the current prevalence of diabetes and its etiology among hospitalized Jordanian adults. METHODS This was a cross sectional study conducted at Specialist Hospital (SH) in the Jordanian capital of Amman, with data collection taking place between June and August 2015, and data was extracted manually from medical records. Patients were divided into three groups: (a) those with a medical history of diabetes, (b) those with unrecognized diabetes or new hyperglycemia, and (c) those with no diabetes. Data management and analysis were conducted using the SPSS program. Means ±SD were used to present all continuous variables, as well as the numbers and percentages for categorical variables, and we used analysis of variance (ANOVA) to compare between means. For differences between categorical variables, we used (x(2)). A P-value of less than 0.05 was considered significant. RESULTS A total of 392 patients (266 female, 126 male) were admitted during the 10-week study period. Of these, 204 fell into category (a), 45 into category (b), and 143 into category (c). Diabetes was the principal diagnosis in 52% of the hospitalizations. Patients who had diabetes or new hyperglycemia were considerably older than non-diabetic patients. The five most common reasons for hospitalization were congestive heart failure (25.0%), pneumonia (22.5%), DKA (22.0%), coronary atherosclerosis (16.20%), and septicemia (14.20%). CONCLUSION The common etiologies for hospitalization were congestive heart failure, pneumonia, DKA, coronary atherosclerosis, and septicemia. Keeping in view the results of this study it is recommend that regular screening should be performed for diabetic patients, as this will increase the chances that many diabetes complications will be prevented, particularly for elderly subjects.
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Affiliation(s)
- Amal K Suleiman
- Pharmaceutical Practices Department, Pharmacy College, Princess Noura bint Abdul Rahman University, Riyadh 11671, Saudi Arabia.
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Wong B, Cheng A, Yu C, Goguen J. Examining the "Killer K" of Diabetic Ketoacidosis at a Tertiary Care Hospital: An Exploratory Study. Can J Diabetes 2016; 40:204-9. [PMID: 26970890 DOI: 10.1016/j.jcjd.2015.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 09/09/2015] [Accepted: 10/09/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Hypokalemia, a frequently cited complication of diabetic ketoacidosis (DKA) treatment, can have critical implications, including arrhythmias and death. We assessed the prevalence of hypokalemia and its associated factors in patients with DKA at our tertiary-care centre and identified opportunities to improve care. METHODS We conducted a retrospective chart review to establish the prevalence of hypokalemia in patients diagnosed with DKA between July 2012 and July 2013. A focused root-cause analysis was subsequently performed to identify Canadian Diabetes Association DKA clinical practice guideline deviations and preventable errors that resulted in significant hypokalemia (K<3.3 mmol/L) during the first 48 hours of management. Clinical and management details were reviewed to determine the type, preventability and root cause(s) of each error. RESULTS We identified 40 cases of DKA during the study period. The overall prevalence of hypokalemia during DKA treatment was 38% (15/40), with 25% in type 1 and 56% in type 2 diabetes. Males were more likely to experience hypokalemia (87%), and 47% of hypokalemic incidents occurred in the first presentation of diabetes. All 10 cases of significant hypokalemia were reviewed. We identified 23 errors in 6 (60%) cases, of which 87% were deemed to be preventable. The most common errors were noncessation of insulin infusion during hypokalemia (60%), inadequate potassium supplementation (50%) and infrequent biochemical monitoring (50%). CONCLUSIONS Hypokalemia occurs frequently during acute DKA management and is often preventable. Our findings suggest that interventions targeted at enhancing awareness of guidelines may reduce hypokalemia rates.
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Affiliation(s)
- Bertha Wong
- University of Toronto, Toronto, Ontario, Canada; University of Ottawa, Ottawa, Ontario, Canada
| | - Amy Cheng
- University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada
| | - Catherine Yu
- University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannette Goguen
- University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada.
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Dhatariya K, Nunney I, Iceton G. Institutional factors in the management of adults with diabetic ketoacidosis in the UK: results of a national survey. Diabet Med 2016; 33:269-70. [PMID: 26235104 DOI: 10.1111/dme.12877] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2015] [Indexed: 01/02/2023]
Affiliation(s)
- K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - I Nunney
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - G Iceton
- Clinical Audit and Improvement Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Dhatariya KK, Nunney I, Higgins K, Sampson MJ, Iceton G. National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014. Diabet Med 2016; 33:252-60. [PMID: 26286235 DOI: 10.1111/dme.12875] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2015] [Indexed: 01/21/2023]
Abstract
AIM To examine, in a national survey, the outcomes of adult patients presenting with DKA in 2014, mapped against accepted UK national guidance. METHODS Data were collected in a standardized form covering clinical and biochemical outcomes, risk and discharge planning. The form was sent to all UK diabetes specialist teams (n = 220). Anonymized data were collected on five consecutive patients admitted with DKA between 1 May 2014 and 30 November 2014. RESULTS A total of 283 forms were received (n = 281 patients) from 72 hospitals, of which 71.4% used the national guidelines. The results showed that 7.8% of cases occurred in existing inpatients, 6.1% of admissions were newly diagnosed diabetes and 33.7% of patients had had at least one episode of DKA in the preceding year. The median times to starting 0.9% sodium chloride and intravenous insulin were 41.5 and 60 min, respectively. The median time to resolution was 18.7 h and the median length of hospital stay was 2.6 days. Significant adverse biochemical outcomes occurred, with 27.6% of patients developing hypoglycaemia and 55% reported as having hypokalaemia. There were also significant issues with care processes. Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of the diabetes specialist team during the first 6 h, but 95% were seen before discharge. A significant minority of discharge letters to primary care did not contain necessary information. CONCLUSION Despite widespread adoption of national guidance, several areas of management of DKA are suboptimal, being associated with avoidable biochemical and clinical risk.
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Affiliation(s)
- K K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich
| | - I Nunney
- Norwich Medical School, University of East Anglia, Norwich
| | - K Higgins
- University Hospitals of Leicester NHS Trust, Leicester
| | - M J Sampson
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich
| | - G Iceton
- Clinical Audit and Improvement Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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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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Venkatesh B, Pilcher D, Prins J, Bellomo R, Morgan TJ, Bailey M. Incidence and outcome of adults with diabetic ketoacidosis admitted to ICUs in Australia and New Zealand. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:451. [PMID: 26715333 PMCID: PMC4699354 DOI: 10.1186/s13054-015-1171-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/15/2015] [Indexed: 12/22/2022]
Abstract
Background Over the last two decades, there have been several improvements in the management of diabetes. Whether this has impacted on the epidemiology and outcome of diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission is unknown. Method This was a retrospective study of 8533 patients with the diagnosis of DKA admitted to 171 ICUs in Australia and New Zealand between 2000–2013 with separate independent analysis of those on established insulin (Group I) or not on insulin (Group NI) at the time of hospitalisation. Results Of the 8553 patients, 2344 (27 %) were identified as NI. The incidence of ICU admission with DKA progressively increased fivefold from 0.97/100,000 (95 % CI 0.84–1.10) in 2000 to 5.3/100,000 (95 % CI 4.98–5.53) in 2013 (P < 0.0001), with the proportions between I and NI remaining stable. Rising incidences were observed mainly in rural and metropolitan hospitals (P < 0.01). In the first 24 hours in the ICU, mean worst pH increased over the study period from 7.20 ± 0.02 to 7.24 ± 0.01 (P < 0.0001), and mean lowest plasma bicarbonate from 12.1 ± 6.6 to 13.8 ± 6.6 mmol/L (P < 0.0001). In contrast, mean highest plasma glucose decreased from 26.3 ± 14 to 23.2 ± 13.1 mmol/L (P < 0.0001). Hospital mortality was significantly greater in NI as compared to I (2.4 % vs 1.1 %, P > 0.0001). Elevated plasma urea in the first 24 hours (≥25 mmol/L, adjusted odds ratio 20.6 (6.54–65.7), P < 0.0001) was the strongest individual predictor of mortality. Conclusions The incidence of ICU admission of patients with DKA in Australia and New Zealand has increased fivefold over the last decade, with a significant proportion of patients not on insulin at presentation. Overall physiological status in the first 24 hours of ICU admission has progressively improved and mortality rates have remained stable. However, DKA patients not on established insulin therapy at presentation had significantly worse outcomes. This notion has epidemiologic, diagnostic and management implications.
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Affiliation(s)
- Balasubramanian Venkatesh
- Intensive Care, Wesley and Princess Alexandra Hospitals, University of Queensland, Brisbane, Queensland, Australia.
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia. .,Australian and New Zealand Intensive Care Research Centre, ANZICS Centre for Outcome and Resource Evaluation CORE, Melbourne, Victoria, Australia.
| | - John Prins
- Endocrinology, University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
| | - Rinaldo Bellomo
- Intensive Care, Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia.
| | - Thomas John Morgan
- Mater Misericordiae Hospital, Mater Research Institute - UQ, South Brisbane, Brisbane, Queensland, Australia.
| | - Michael Bailey
- Epidemiologist, Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia.
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DiFazio J, Fletcher DJ. Retrospective comparison of early- versus late-insulin therapy regarding effect on time to resolution of diabetic ketosis and ketoacidosis in dogs and cats: 60 cases (2003-2013). J Vet Emerg Crit Care (San Antonio) 2015; 26:108-15. [PMID: 26551019 DOI: 10.1111/vec.12415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 09/28/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether early insulin administration (≤6 h after admission) results in more rapid resolution of diabetic ketosis (DK) and ketoacidosis (DKA), shorter duration of hospitalization, and higher incidence of complications, and whether more severe ketonuria is associated with longer time to resolution of DK/DKA. DESIGN Retrospective study (January 1, 2003-March 1, 2013). SETTING University teaching hospital. ANIMALS Sixty dogs and cats with DK or DKA receiving short-acting insulin therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Medical records were reviewed and data recorded including signalment; previous history of diabetes; intake temperature, blood pressure, blood glucose, pH, base excess, and degree of ketonuria; time to short-acting insulin therapy and resolution of DK/DKA; length of hospitalization; and complications. Insulin was initiated ≤6 hours in the early group and >6 hours in the late group after hospital admission. Early group patients had more rapid resolution of DK/DKA after starting short-acting insulin therapy (36.4 ± 22.6 vs. 55.4 ± 26.6 h, P = 0.014). There was no difference in duration of hospitalization or complications. More severe ketonuria resulted in longer time to resolution of DK/DKA after initiation of short-acting insulin (severe: 50.9 ± 24.2; moderate: 29.6 ± 19; mild: 23.4 ± 21.9 h, P = 0.005, all individual pairwise comparisons P < 0.05). CONCLUSIONS Early insulin administration is associated with more rapid resolution of DK/DKA without an associated increase in complication rates. DK/DKA took longer to resolve with more severe ketonuria. Prospective studies are warranted to identify specific time targets for insulin administration in DK/DKA patients.
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Affiliation(s)
- Jillian DiFazio
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, 14853
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, 14853
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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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Doshi P, Potter AJ, De Los Santos D, Banuelos R, Darger BF, Chathampally Y. Prospective randomized trial of insulin glargine in acute management of diabetic ketoacidosis in the emergency department: a pilot study. Acad Emerg Med 2015; 22:657-62. [PMID: 26013711 DOI: 10.1111/acem.12673] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/21/2014] [Accepted: 12/09/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to determine the efficacy of coadministration of subcutaneous (SQ) insulin glargine in combination with intravenous (IV) insulin for treating diabetic ketoacidosis (DKA). METHODS This was a prospective, randomized, controlled trial comparing coadministration of insulin glargine and IV insulin (experimental) with IV insulin (standard care control). The setting was emergency departments (EDs) in two hospitals in Houston, Texas. Patients presenting with blood sugar ≥ 200 mg/dL, pH ≤ 7.3, bicarbonate (HCO3 ) ≤ 18 mg/dL, ketonemia or ketonuria, and anion gap ≥ 16 between November 2012 and April 2013 were enrolled. All patients received IV insulin. Additionally, the experimental group was given SQ insulin glargine within 2 hours of diagnosis. Upon closure of anion gap, patients in the control group were subsequently transitioned to long-acting insulin. In the study group, IV insulin was discontinued and long-acting SQ insulin was reinstituted 24 hours after initial introduction. The primary outcome of time to closure of anion gap (TCAG) was compared between groups using a general linear model (GLM), adjusting for initial anion gap, etiology, and presence of comorbidities. Similarly, the secondary outcome hospital length of stay (LOS) was adjusted for age, etiology, and hospital site in the GLM. Rate of hypoglycemia and intensive care unit (ICU) admission was compared using Fisher's exact test while ICU LOS was compared using Wilcoxon's two-sample test. RESULTS A total of 40 patients were enrolled in this pilot trial. The estimated mean TCAG was 10.2 hours (SE ± 6.8 hours) in the experimental group and 11.6 hours (SE ± 6.4 hours) in the control group (p = 0.63). The estimated mean hospital LOS was 3.9 days (SE ± 3.4 days) in the experimental group and 4.8 days (SE ± 3.6 days) in the control group (p = 0.66). Incidents of hypoglycemia, rates of ICU admission, and ICU LOS were similar between the groups. CONCLUSIONS Coadministration of glargine in combination with an insulin infusion in the acute management of DKA is feasible. Further study is needed to determine the true efficacy in terms of TCAG and hospital LOS.
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Affiliation(s)
- Pratik Doshi
- Department of Emergency Medicine; University of Texas Health Science Center at Houston; Houston TX
| | - Andrew J. Potter
- Department of Emergency Medicine; University of Texas Health Science Center at Houston; Houston TX
| | - Daniel De Los Santos
- Department of Emergency Medicine; University of Texas Health Science Center at Houston; Houston TX
| | - Rosa Banuelos
- Department of Emergency Medicine; University of Texas Health Science Center at Houston; Houston TX
| | | | - Yashwant Chathampally
- Department of Emergency Medicine; University of Texas Health Science Center at Houston; Houston TX
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Al-Adsani AM, Abdulla KA. Reasons for hospitalizations in adults with diabetes in Kuwait. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ijdm.2011.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
PURPOSE OF REVIEW Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology. RECENT FINDINGS Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking. SUMMARY Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.
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Affiliation(s)
- Joanna Hart
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott D. Halpern
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Epidemiology and Biostatistics and Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Orban JC, Maizière EM, Ghaddab A, Van Obberghen E, Ichai C. Incidence and characteristics of acute kidney injury in severe diabetic ketoacidosis. PLoS One 2014; 9:e110925. [PMID: 25338064 PMCID: PMC4206473 DOI: 10.1371/journal.pone.0110925] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 09/13/2014] [Indexed: 12/11/2022] Open
Abstract
Aims Acute kidney injury is a classical complication of diabetic ketoacidosis. However, to the best of our knowledge, no study has reported the incidence and characteristics of acute kidney injury since the consensus definition was issued. Methods Retrospective study of all cases of severe diabetic ketoacidosis hospitalised consecutively in a medical surgical tertiary ICU during 10 years. Patients were dichotomised in with AKI and without AKI on admission according to the RIFLE classification. Clinical and biological parameters were compared in these populations. Risk factors of presenting AKI on admission were searched for. Results Ninety-four patients were included in the study. According to the RIFLE criteria, 47 patients (50%) presented acute kidney injury on admission; most of them were in the risk class (51%). At 12 and 24 hours, the percentage of AKI patients decreased to 26% and 27% respectively. During the first 24 hours, 3 patients needed renal replacement therapy. Acute renal failure on admission was associated with a more advanced age, SAPS 2 and more severe biological impairments. Treatments were not different between groups except for insulin infusion. Logistic regression found 3 risk factors of presenting AKI on admission: age (odds ratio 1.060 [1.020–1.100], p<0.01), blood glucose (odds ratio 1.101 [1.039–1.166], p<0.01) and serum protein (odds ratio 0.928 [0.865–0.997], p = 0.04). Conclusions Acute kidney injury is frequently associated with severe diabetic ketoacidosis on admission in ICU. Most of the time, this AKI is transient and characterised by a volume-responsiveness to fluid infusion used in DKA treatment. Age, blood glucose and serum protein are associated to the occurrence of AKI on ICU admission.
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Affiliation(s)
- Jean-Christophe Orban
- Réanimation médico-chirurgicale, Hôpital Saint-Roch, CHU de Nice, Nice, France
- IRCAN, Faculté de Médecine, Université de Nice Sophia-Antipolis, Nice, France
- * E-mail:
| | - Eve-Marie Maizière
- Réanimation médico-chirurgicale, Hôpital Saint-Roch, CHU de Nice, Nice, France
| | - Anis Ghaddab
- Réanimation médico-chirurgicale, Hôpital Saint-Roch, CHU de Nice, Nice, France
| | - Emmanuel Van Obberghen
- IRCAN, Faculté de Médecine, Université de Nice Sophia-Antipolis, Nice, France
- Laboratoire de Biochimie, CHU de Nice, Nice, France
| | - Carole Ichai
- Réanimation médico-chirurgicale, Hôpital Saint-Roch, CHU de Nice, Nice, France
- IRCAN, Faculté de Médecine, Université de Nice Sophia-Antipolis, Nice, France
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Improving Glucose Management with Point-of-Care Testing in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014. [DOI: 10.1007/s40138-014-0048-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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