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Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024; 47:1257-1275. [PMID: 39052901 PMCID: PMC11272983 DOI: 10.2337/dci24-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 07/27/2024]
Abstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.
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Affiliation(s)
- Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Georgia M. Davis
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Nuha A. ElSayed
- American Diabetes Association, Arlington, VA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Gian Paolo Fadini
- Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Rodolfo J. Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Irl B. Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
| | - Rozalina G. McCoy
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
- University of Maryland Institute for Health Computing, Bethesda, MD
| | - Shivani Misra
- Division of Metabolism, Digestion & Reproduction, Imperial College London, U.K
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, U.K
| | - Robert A. Gabbay
- American Diabetes Association, Arlington, VA
- Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Ketan K. Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, U.K
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, U.K
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Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia 2024; 67:1455-1479. [PMID: 38907161 PMCID: PMC11343900 DOI: 10.1007/s00125-024-06183-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 06/23/2024]
Abstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Georgia M Davis
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nuha A ElSayed
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gian Paolo Fadini
- Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Rodolfo J Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Rozalina G McCoy
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland Institute for Health Computing, Bethesda, MD, USA
| | - Shivani Misra
- Division of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Robert A Gabbay
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
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Alnuaimi A, Mach T, Reynier P, Filion KB, Lipes J, Yu OHY. A systematic review and meta-analysis comparing outcomes between using subcutaneous insulin and continuous insulin infusion in managing adult patients with diabetic ketoacidosis. BMC Endocr Disord 2024; 24:133. [PMID: 39090718 PMCID: PMC11293178 DOI: 10.1186/s12902-024-01666-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis was to synthesize the current literature to determine the safety and efficacy of using subcutaneous insulin compared to an intravenous (IV) insulin infusion in managing diabetic ketoacidosis (DKA). METHODS We searched Ovid-Medline, EMBASE, SCOPUS, BIOSIS and CENTRAL from inception to April 26, 2024. Randomized controlled trials (RCTs) and observational studies that assessed the use of subcutaneous compared to intravenous insulin for the treatment of mild to moderate DKA were included. Data extraction and quality assessment were performed by two independent reviewers and disagreements were resolved through further discussion or by a third reviewer. The Cochrane Risk of Bias tool version 2.0 was used to evaluate the RCTs and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS)-I tool was used to evaluate the observational studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Meta-analyses were conducted using random-effects models. We followed the PRISMA guidelines for reporting our findings. RESULTS Six RCTs (245 participants) and four observational studies (8444 patients) met our inclusion criteria. Some studies showed a decreased length of stay (Mean Difference [MD] in days: -0.39; 95% CI: -2.83 to 2.08; I2: 0%) among individuals treated with subcutaneous insulin compared to intravenous insulin. There was no difference in the risk of all-cause mortality, time to resolution of DKA (MD in hours: 0.17; 95% confidence interval [CI]: -3.45 to 3.79; I2: 0%) and hypoglycemia (Risk Ratio [RR]: 1.02; 95% CI: 0.88 to 1.19; I2: 0%) between the two groups. CONCLUSION Treatment of DKA with subcutaneous insulin may be a safe and effective alternative to IV insulin in selected patients. The limited available evidence underscores the need for further studies to explore optimal dosing, patient selection criteria and long-term outcomes.
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Affiliation(s)
- Ahmed Alnuaimi
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Tiffany Mach
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte Sainte-Catherine, E104, Montreal, QC, H3T 1E2, Canada
| | - Kristian B Filion
- Department of Medicine, McGill University, Montreal, QC, Canada
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte Sainte-Catherine, E104, Montreal, QC, H3T 1E2, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Jed Lipes
- Department of Medicine, Division of Critical Care, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Oriana Hoi Yun Yu
- Department of Medicine, McGill University, Montreal, QC, Canada.
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte Sainte-Catherine, E104, Montreal, QC, H3T 1E2, Canada.
- Division of Endocrinology, Jewish General Hospital, Montreal, QC, Canada.
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Ibarra F, Bae R, Haghighat B. Review of Subcutaneous Insulin Regimens in the Management of Diabetic Ketoacidosis in Adults and Pediatrics. Ann Pharmacother 2024:10600280241263357. [PMID: 39054791 DOI: 10.1177/10600280241263357] [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: 07/27/2024] Open
Abstract
OBJECTIVE Summarize the studies evaluating the use of subcutaneous (SQ) insulin in the management of diabetic ketoacidosis (DKA) in adults and pediatrics. DATA SOURCES A PubMed literature search was conducted for articles published between 2000 and the end of May 2024 which contained the following terms in their title: (1) subcutaneous, glargine, or basal and (2) ketoa*. STUDY SELECTION AND DATA EXTRACTION Review articles, guidelines, meta-analysis, commentaries, studies not related to the acute management of DKA, studies evaluating continuous SQ insulin, animal studies, if the time to DKA resolution was not clearly defined, and studies where basal insulin was administered greater than 6 hours after the insulin infusion was started were excluded. DATA SYNTHESIS The electronic search identified 58 articles. Following the initial screening 38 articles were excluded and 3 were added after bibliography review. Of the 23 articles assessed for eligibility, 7 were excluded. Sixteen articles were included. Five studies compared SQ rapid/short-acting insulin and intravenous (IV) insulin infusions in adults, 4 compared SQ rapid/short-acting insulin and IV insulin infusions in pediatrics, 4 evaluated IV insulin infusions with or without SQ basal insulin in adults, and 3 evaluated IV insulin infusions with or without SQ basal insulin in pediatrics. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE In comparison with IV insulin infusions, rapid/short-acting SQ insulin regimens were associated with reduced ICU admission rates, hospital length of stay, and hospitalization costs. IV insulin infusion regimens that included a single SQ basal insulin dose upon therapy initiation were associated with reduced concurrent IV insulin infusion durations. CONCLUSION Studies reviewed suggest that SQ insulin regimens may be as effective and safe as IV insulin infusions in the management of DKA and are associated with the conservation of resources. Providers may refer to this review when establishing or modifying their DKA management protocols.
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Affiliation(s)
- Francisco Ibarra
- College of Osteopathic Medicine, California Health Sciences University, Clovis, CA, USA
- Department of Pharmacy Services, Community Regional Medical Center, Fresno, CA, USA
- Department of Emergency Medicine, University of California San Francisco at Fresno, Fresno, CA, USA
| | - Ryan Bae
- College of Osteopathic Medicine, California Health Sciences University, Clovis, CA, USA
| | - Bardya Haghighat
- College of Osteopathic Medicine, California Health Sciences University, Clovis, CA, USA
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Griffey RT, Schneider RM, Girardi M, Yeary J, McCammon C, Frawley L, Ancona R, Cruz-Bravo P. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. Acad Emerg Med 2023; 30:800-808. [PMID: 36775281 DOI: 10.1111/acem.14685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Studies using fast-acting subcutaneous (SQ) insulin analogs in diabetic ketoacidosis (DKA) have demonstrated efficacy, safety, and cost-effectiveness, allowing treatment of mild-to-moderate (MTM)-severity DKA patients in non-intensive care unit (ICU) settings. However, emergency department (ED)-based studies are few, with limited exploration of impacts on operational metrics. METHODS We implemented the SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) protocol for adults with MTM-severity DKA in an urban academic ED, collecting data from August 1, 2021, to February 28, 2022. We examined fidelity (frequency of required q2h glucose checks), safety (proportion of patients administered rescue dextrose for hypoglycemia), and ED length of stay (EDLOS) for the SQuID cohort compared to patients (non-ICU) treated with a traditional insulin infusion. We also examined ICU admission rate among MTM-severity DKA patients after introduction of SQuID to two historical control periods (pre-intervention and pre-COVID). We used Mann-Whitney U to test for differences in EDLOS distributions, bootstrapped (n = 1000) confidence intervals (CIs) for EDLOS median differences, and the two-sample z-test for differences in ICU admissions. RESULTS We identified 177 MTM-severity DKA patients in the study period (78 SQuID, 99 traditional cohort) and 163 preintervention and 161 pre-COVID historical control patients. Fidelity to the SQuID pathway was good, with glucose checks exceeding the q2-h requirement. We found no difference in the proportion of rescue dextrose administration compared to the traditional pathway. We observed significant reductions in median EDLOS for the SQuID cohort compared to the traditional cohort during the study period (-3.0, 95% CI -8.5 to -1.4), the preintervention period (-1.4, 95% CI -3.1 to -0.1), and the pre-COVID control period (-3.6, 95% CI -7.5 to -1.8). CONCLUSIONS In this single-center study at an academic ED, treatment of patients with MTM-severity DKA with a SQ insulin protocol was effective, demonstrated equivalent safety, and reduced ED length of stay.
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Affiliation(s)
- Richard T Griffey
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ryan M Schneider
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Margo Girardi
- Department of Internal Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Julianne Yeary
- Barnes-Jewish Hospital Emergency Department, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Craig McCammon
- Barnes-Jewish Hospital Emergency Department, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Laura Frawley
- Barnes-Jewish Hospital Emergency Department, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Rachel Ancona
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Paulina Cruz-Bravo
- Department of Internal Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
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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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Alshurtan KS, Alnizari O, Aldarwish H, Al-Tufaif AA. Efficacy and Safety of Intravenous Insulin in Treatment of Patient With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30721. [DOI: 10.7759/cureus.30721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/07/2022] Open
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Yoo MS, Daniels A, Maslow RA, Gomez JA, Meyers NL, Bohrer PS, Nemazie S, Sanford CE, Peterson EA, Hamann KL, Walsh DE, O’Herlihy AM, Kumra V. Management of hospitalized patients with mild to moderate diabetic ketoacidosis using a continuous insulin infusion protocol on a medical surgical ward and observation level of care: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e29665. [PMID: 35945801 PMCID: PMC9351868 DOI: 10.1097/md.0000000000029665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Although the practice of using rapid-acting subcutaneous insulin for the management of mild-to-moderate diabetic ketoacidosis is becoming increasingly popular, the continuous insulin infusion remains widely utilized, and its real-world applicability and safety on a medical surgical unit (Med Surg) and observation level of care are unclear. We assessed whether a continuous insulin infusion protocol for mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care over a 6.5-year period was associated with adverse outcomes. A retrospective cohort study of adults hospitalized with mild-to-moderate diabetic ketoacidosis was conducted at 2 community hospitals in Northern California, USA, from January 2014 to May 2020. Demographic and clinical variables were collected using an electronic health record. Admission to Med Surg/observation was compared to intensive care unit admission for the outcomes of 30-day readmission, presence of hypoglycemia, rate of hypoglycemic episodes, in-hospital and 30-day mortality, and length of stay using bivariate analysis. Among 227 hospital encounters (mean age 41 years, 52.9% women, 79.3% type 1 diabetes, 97.4% utilization of continuous insulin infusion), 19.4% were readmitted within 30 days, and 20.7% developed hypoglycemia. For Med Surg/observation encounters compared to the intensive care unit, there were no statistically significant differences in the risk of readmission (RR 1.48, 95% CI, 0.86-2.52), hypoglycemia (RR 1.17, 95% CI, 0.70-1.95), or increased length of stay (RR 0.71, 95% CI, 0.55-1.02); there was a lower risk of hypoglycemic events during hospitalization (RR 0.69, 95% CI, 0.54-0.96). Continuous insulin infusion utilization may be a safe option for treatment of mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care. Further investigation is needed.
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Affiliation(s)
- Michael S. Yoo
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
- *Correspondence: Michael S. Yoo, Kaiser Permanente Santa Rosa Medical Center, 401 Bicentennial Way, Santa Rosa, CA 95403, USA (e-mail: )
| | - Abraham Daniels
- Department of Medical Administration Strategic Activities, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Rene A. Maslow
- Department of Critical Care, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - John A. Gomez
- Department of National Quality, Safety, Experience and Health Systems Performance, Kaiser Permanente, Oakland, CA, USA
| | - Nannette L. Meyers
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Pamela S. Bohrer
- Department of Head and Neck Surgery, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Siamack Nemazie
- Department of Nephrology, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Christina E. Sanford
- Department of Clinical Adult Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Emily A. Peterson
- Department of Inpatient Pharmacy Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Kendal L. Hamann
- Department of Endocrinology, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Darcy E. Walsh
- Department of Oncology and Adult Infusion, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Alison M. O’Herlihy
- Department of Clinical Adult Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Vivek Kumra
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
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Rao P, Jiang SF, Kipnis P, Patel DM, Katsnelson S, Madani S, Liu VX. Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis. JAMA Netw Open 2022; 5:e226417. [PMID: 35389497 PMCID: PMC8990349 DOI: 10.1001/jamanetworkopen.2022.6417] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/21/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Standard diabetic ketoacidosis care in the US includes intravenous insulin treatment in the intensive care unit. Subcutaneous (SQ) insulin could decrease intensive care unit need, but the data are limited. Objective To assess outcomes after implementation of an SQ insulin protocol for treating diabetic ketoacidosis. Design, Setting, and Participants This cohort study is a retrospective evaluation of a prospectively implemented SQ insulin protocol. The study was conducted at an integrated health care system in Northern California. Participants included hospitalized patients with diabetic ketoacidosis at 21 hospitals between January 1, 2010, and December 31, 2019. The preimplementation phase was 2010 to 2015, and the postimplementation phase was 2017 to 2019. Data analysis was performed from October 2020 to January 2022. Exposure An SQ insulin treatment protocol for diabetic ketoacidosis. Main Outcomes and Measures Difference-in-differences evaluation of the need for intensive care, mortality, readmission, and length of stay at a single intervention site using an SQ insulin protocol from 2017 onward compared with 20 control hospitals using standard care. Results A total of 7989 hospitalizations for diabetic ketoacidosis occurred, with 4739 (59.3%) occurring before and 3250 (40.7%) occurring after implementation. The overall mean (SD) age was 42.3 (17.7) years, with 4137 hospitalizations (51.8%) occurring among female patients. Before implementation, SQ insulin was the first insulin used in 40 intervention (13.4%) and 651 control (14.7%) hospitalizations. After implementation, 98 hospitalizations (80.3%) received SQ insulin first at the intervention site compared with 402 hospitalizations (12.8%) at control sites. The adjusted rate ratio for intensive care unit admission was 0.43 (95% CI, 0.33-0.56) at the intervention sites, a 57% reduction compared with control sites, and was 0.50 (95% CI, 0.25-0.99) for 30-day hospital readmission, a 50% reduction. There were no significant changes in hospital length of stay and rates of death. Conclusions and Relevance These findings suggest that a protocol based on SQ insulin for diabetic ketoacidosis treatment was associated with significant decreases in intensive care unit need and readmission, with no evidence of increases in adverse events.
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Affiliation(s)
- Priya Rao
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | | | - Patricia Kipnis
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
| | - Divyesh M. Patel
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | - Svetlana Katsnelson
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | - Samineh Madani
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | - Vincent X. Liu
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
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10
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Chow L, Valesky W. Subcutaneous Rapid-acting Insulin Analogs for Diabetic Ketoacidosis. Acad Emerg Med 2021; 28:700-702. [PMID: 33145848 DOI: 10.1111/acem.14170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Lillian Chow
- From the Department of Medicine Division of Pulmonary and Critical Care Medicine SUNY Downstate Health Sciences University Brooklyn NY USA
| | - Walter Valesky
- and the Department of Emergency Medicine Kings County Hospital–NYC Health + Hospitals Brooklyn NY USA
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11
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Beaudoin ML, Torrents M, Tittarelli MF, Hamui M, Ibarra M, Ferraro M, Ferreira JP. Use of a Flexible Catheter for the Administration of Subcutaneous Insulin in Diabetic Ketoacidosis: A Feasibility Controlled Clinical Trial. Hosp Pediatr 2021; 11:396-400. [PMID: 33687988 DOI: 10.1542/hpeds.2020-0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although intravenous insulin administration is the standard of care in diabetic ketoacidosis (DKA), subcutaneous insulin administration could be a suitable alternative in resource-limited settings, but pain caused by hourly insulin applications are limiting factors for using it, especially in children. We aimed to assess whether the use of a flexible subcutaneous catheter improves comfort in patients with DKA compared with the usual hourly injections' treatment. We also compared the evolution of metabolic variables in patients with DKA using both insulin administration systems. METHODS Randomized feasibility controlled open trial, comparing 2 ways (flexible catheter and steel needle) for the initial insulin administration in children with DKA, who were randomly selected to receive subcutaneous insulin by a flexible catheter or using standard needles. The main outcome was pain, assessed hourly and secondary outcome time to achieve ketoacidosis resolution. RESULTS Twenty subjects were included (10 by group). There were no differences between groups in baseline lab values (glycemia, urea, sodium, bicarbonate and pH). Pain assessment at first insulin administration was significantly lower in the intervention group (4.5 vs 0 points; P = 0.001). Similar differences between both treatment arms were observed in every pain assessment. There were no differences between groups regarding the time elapsed to achieve ketoacidosis resolution. (11.4±4.3 vs 16±8.4; P = 0.12). No adverse events or DKA complications were observed. CONCLUSIONS The use of a flexible catheter reduced the pain associated with subcutaneous insulin administration in nonsevere DKA. The flexible subcutaneous catheter could be a safe alternative for the treatment of uncomplicated DKA in resource-limited settings.
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Affiliation(s)
| | - Milagros Torrents
- Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | | | - Magali Hamui
- Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Mariano Ibarra
- Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Mabel Ferraro
- Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
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12
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Priyambada L, Wolfsdorf JI, Brink SJ, Fritsch M, Codner E, Donaghue KC, Craig ME. ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of COVID-19 and resource-limited settings-role of subcutaneous insulin. Pediatr Diabetes 2020; 21:1394-1402. [PMID: 32935435 DOI: 10.1111/pedi.13118] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/19/2020] [Accepted: 08/19/2020] [Indexed: 01/08/2023] Open
Abstract
The International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guideline 2018 for management of diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state provide comprehensive guidance for management of DKA in young people. Intravenous (IV) infusion of insulin remains the treatment of choice for treating DKA; however, the policy of many hospitals around the world requires admission to an intensive care unit (ICU) for IV insulin infusion. During the coronavirus 2019 (COVID-19) pandemic or other settings where intensive care resources are limited, ICU services may need to be prioritized or may not be appropriate due to risk of transmission of infection to young people with type 1 or type 2 diabetes. The aim of this guideline, which should be used in conjunction with the ISPAD 2018 guidelines, is to ensure that young individuals with DKA receive management according to best evidence in the context of limited ICU resources. Specifically, this guideline summarizes evidence for the role of subcutaneous insulin in treatment of uncomplicated mild to moderate DKA in young people and may be implemented if administration of IV insulin is not an option.
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Affiliation(s)
- Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stuart J Brink
- New England Diabetes and Endocrinology Center, Waltham, Massachusetts, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
| | - Kim C Donaghue
- Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Maria E Craig
- Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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13
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Vidyasagar K, Chandrasekar B, Chhabra M, Bhansali A, Bansal D. Efficacy and Safety of Commonly Used Insulin Analogues in the Treatment of Diabetic Ketoacidosis: A Bayesian Indirect Treatment Comparison. Clin Ther 2020; 42:e115-e139. [PMID: 32798057 DOI: 10.1016/j.clinthera.2020.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Insulin analogues (IAs) are the mainstay for the management of diabetic ketoacidosis (DKA). However, the relative efficacy of newer IAs is uncertain. The aim of this study was to compare the relative efficacy and safety of IAs for the management of DKA using an indirect treatment comparison (ITC). METHODS PubMed, EMBASE, Scopus, the Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing short-, rapid-, and long-acting IAs in patients with DKA. The primary outcomes of interest were time taken to normalize DKA and time taken to normalize blood glucose levels. The secondary outcomes of interest were the amount of insulin needed to normalize DKA, the length of hospital stay, and the number of hypoglycemic events in the intervention and comparator groups. Bayesian ITC was performed by using the gemtc package in the R program. Continuous outcomes are reported as mean difference (MD), and binary outcomes are reported as odds ratios (ORs), with 95% credible intervals (CrIs). The Cochrane risk of bias tool was used to assess the risk of bias in the included RCTs. FINDINGS Ten RCTs randomizing 435 participants to treatment were included in this ITC. A total of 5 interventions (lispro, glargine with regular insulin [RI], glulisine, aspart, and regular insulin) were compared for both safety and efficacy outcomes in DKA. Glargine co-administered with regular insulin showed superiority for clinical outcomes compared with regular insulin: consuming less time (MD, -3.1 h; 95% CrI, -7.9 to 1.8), amount of insulin required (MD, -32 U; 95% CrI, 83.0 to 18.0), and the length of hospitalization (MD, -0.82 day; 95% CrI, -2.7 to 1.0) to normalize DKA. However, these results were not statistically significant. Insulin aspart had fewer reports of hypoglycemic events (OR, 1.7; 95% CrI, 0.34 to 9.3) than regular insulin. IMPLICATIONS Newer IAs were found to be equally effective and safe as regular insulin in the treatment of DKA. Thus, administering these IAs can be considered a safe and cost-effective alternative for DKA management in non-ICU settings. Cost-effective analysis of the newer IAs is needed because these agents are expensive compared with regular insulin.
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Affiliation(s)
- Kota Vidyasagar
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
| | - Boya Chandrasekar
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
| | - Manik Chhabra
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Dipika Bansal
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
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14
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Palermo NE, Sadhu AR, McDonnell ME. Diabetic Ketoacidosis in COVID-19: Unique Concerns and Considerations. J Clin Endocrinol Metab 2020; 105:5857202. [PMID: 32556147 PMCID: PMC7337869 DOI: 10.1210/clinem/dgaa360] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/05/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT While individuals with diabetes appear to be at similar risk for SARS-CoV-2 infection to those without diabetes, they are more likely to suffer severe consequences, including death. Diabetic ketoacidosis (DKA) is a common and potentially lethal acute complication of diabetes arising from a relative insulin deficiency, which occurs more often in those with type 1 diabetes and in the setting of moderate to severe illness. Early reports indicate that among patients with pre-existing diabetes, DKA may be a common complication of severe COVID-19 and a poor prognostic sign. CASE DESCRIPTION This clinical perspective explores the key elements of caring for individuals with DKA during the COVID-19 pandemic through 2 cases. Topics addressed include diagnosis, triage, and the fundamental principles of treatment with a focus on the importance of characterizing DKA severity and medical complexity to determine the best approach. CONCLUSIONS As discussed, some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing transmission to highest risk individuals, reducing healthcare worker exposure to infected patients, and preserving personal protective equipment. Evidence for alternative treatment strategies is explored, with special attention placed on treatment options that may be more relevant during the pandemic, including use of subcutaneous insulin therapy. Finally, DKA is often a preventable condition. We include evidence-based strategies and guidance designed to empower clinicians and patients to avoid this serious complication when possible.
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Affiliation(s)
- Nadine E Palermo
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology, Diabetes and Hypertension, Boston, Massachusetts
| | - Archana R Sadhu
- Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas
| | - Marie E McDonnell
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology, Diabetes and Hypertension, Boston, Massachusetts
- Correspondence and Reprint Requests: Marie E. McDonnell, MD, Director, Brigham and Women’s Hospital Diabetes Program, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115, USA. E-mail:
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15
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Abstract
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, CA, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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16
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Sagy I, Zimhony-Nissim N, Brandstaetter E, Lipnitzki I, Musa H, Rosen Y, Barski L. Outcomes of diabetic ketoacidosis in a tertiary centre with restricted intensive care unit bed capacity. Intern Med J 2020; 51:948-954. [PMID: 32253805 DOI: 10.1111/imj.14842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute metabolic condition, sometimes requiring admission to an intensive care unit (ICU). AIMS To investigate the outcomes of DKA patients admitted to a hospital with restricted ICU capacity. METHODS We included all DKA patients above age 18 who were admitted to a tertiary hospital during 2004-2017. We conducted multivariate logistic regression analysis adjusted for ICU bed availability to analyse parameters associated with ICU admission, and a composite outcome of mortality, DKA recurrence and mechanical ventilation. RESULTS Among 382 DKA patients in our cohort, 94 (24.6%) were admitted to the ICU. The in-hospital mortality was 4.7%. Low bicarbonate (<10 mmoL/L) and pH (<7) levels at presentation were associated with ICU admission (P < 0.001 for both). In multivariate models availability of beds in the ICU was not associated with ICU admission, mortality or DKA recurrence of any type. CONCLUSION In a setting of limited ICU capacity, DKA treatment does not necessarily require admission to the ICU. When the rising rates of diabetes mellitus and the associated elevated rates of DKA are taken into account, our results highlight the importance of including step-down units when devising local protocols for care of these patients.
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Affiliation(s)
- Iftach Sagy
- Clinical Research Center, Soroka University Medical Center, Beersheva, Israel.,Internal Medicine Division, Soroka University Medical Center, Beersheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel
| | - Noa Zimhony-Nissim
- Clinical Research Center, Soroka University Medical Center, Beersheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel
| | - Evgenia Brandstaetter
- Internal Medicine Division, Soroka University Medical Center, Beersheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel
| | - Inna Lipnitzki
- Internal Medicine Division, Soroka University Medical Center, Beersheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel
| | - Hadeel Musa
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel
| | - Yakov Rosen
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Israel
| | - Leonid Barski
- Internal Medicine Division, Soroka University Medical Center, Beersheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel
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17
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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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18
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnostic et Prise en Charge de l’Acidose Métabolique Recommandations formalisées d’experts communes Société de réanimation de langue française (SRLF) – Société française de médecine d’urgence (SFMU). ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
L’acidose métabolique est un trouble fréquemment rencontré en médecine d’urgence et en médecine intensive réanimation. La littérature s’étant enrichie de nouvelles données concernant la prise en charge de l’acidose métabolique, la Société de Réanimation de Langue Française (SRLF) et la Société Française de Médecine d’Urgence (SFMU) ont élaboré des recommandations formalisées d’experts selon la méthodologie GRADE. Les champs de la stratégie diagnostique, de l’orientation et de la prise en charge thérapeutique ont été traités et vingt-neuf recommandations ont été formulées : quatre recommandations fortes (Grade 1), dix recommandations faibles (Grade 2) et quinze avis d’experts. Toutes ont obtenu un accord fort. L’application des méthodes d’Henderson-Hasselbalch et de Stewart pour le diagnostic du mécanisme de l’acidose métabolique est discutée et un algorithme diagnostique est proposé. L’utilisation de la cétonémie et des lactatémies veineuse et capillaire est également traitée. L’intérêt du pH, de la lactatémie et de sa cinétique pour l’orientation des patients en pré-hospitalier et aux urgences est envisagé. Enfin, les modalités de l’insulinothérapie au cours de l’acidocétose diabétique, les indications de la perfusion de bicarbonate de sodium et de l’épuration extra-rénale ainsi que les modalités de la ventilation mécanique au cours des acidoses métaboliques sévères sont traitées dans la prise en charge thérapeutique.
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19
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care 2019; 9:92. [PMID: 31418093 PMCID: PMC6695455 DOI: 10.1186/s13613-019-0563-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023] Open
Abstract
Metabolic acidosis is a disorder frequently encountered in emergency medicine and intensive care medicine. As literature has been enriched with new data concerning the management of metabolic acidosis, the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence [SFMU]) have developed formalized recommendations from experts using the GRADE methodology. The fields of diagnostic strategy, patient assessment, and referral and therapeutic management were addressed and 29 recommendations were made: 4 recommendations were strong (Grade 1), 10 were weak (Grade 2), and 15 were experts’ opinions. A strong agreement from voting participants was obtained for all recommendations. The application of Henderson–Hasselbalch and Stewart methods for the diagnosis of the metabolic acidosis mechanism is discussed and a diagnostic algorithm is proposed. The use of ketosis and venous and capillary lactatemia is also treated. The value of pH, lactatemia, and its kinetics for the referral of patients in pre-hospital and emergency departments is considered. Finally, the modalities of insulin therapy during diabetic ketoacidosis, the indications for sodium bicarbonate infusion and extra-renal purification as well as the modalities of mechanical ventilation during severe metabolic acidosis are addressed in therapeutic management.
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Affiliation(s)
- Boris Jung
- Département de Médecine Intensive et Réanimation, CHU Montpellier, 34000, Montpellier, France. .,INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.
| | - Mikaël Martinez
- Pôle Urgence, CH du Forez, 42605, Montbrison, France.,Réseau d'urgence Ligérien Ardèche Nord (REULIAN), Centre Hospitalier Le Corbusier, 42700, Firminy, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse-Grace, Avenue Pasteur, 98012, Monaco, France
| | - Michaël Darmon
- Unité de Médecine Intensive et Réanimation, Hôpital Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Avenue Claude-Vellefaux, 75010, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,France Inserm, ECSTRA Team, UMR 1153, Centre d'Epidémiologie et de Biostatistique, CRESS, Biostatistics and Clinical Epidemiology, Sorbonne-Paris-Cité, Paris, France
| | - Kada Klouche
- INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.,Département de Médecine Intensive-Réanimation, CHU Lapeyronie, 371, Avenue Doyen-Gaston-Giraud, 34295, Montpellier, France
| | - Alexandre Lautrette
- Réanimation, Centre Jean-Perrin, CHU de Clermont-Ferrand, 63000, Clermont-Ferrand, France.,LMGE, UMR CNRS 6023, Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Jacques Levraut
- Département de Médecine d'urgence, CHU de Nice, Hôpital Pasteur-II, 30, Avenue de la Voie Romaine, 06000, Nice, France.,UFR de Médecine, Université de Nice Côte d'Azur, Avenue de Vallombrose, 06000, Nice, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris-VI, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Mathieu Oberlin
- Structure des Urgences, Centre Hospitalier de Cahors, 335, Rue Wilson, 46000, Cahors, France
| | - Nicolas Terzi
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Grenoble, Université de Grenoble, Grenoble, France.,Inserm, U1042, Université Grenoble-Alpes, HP2, 38000, Grenoble, France
| | - Damien Viglino
- Service des Urgences Adultes, CS 10217, CHU Grenoble-Alpes, 38043 Grenoble Cedex 09, Grenoble, France.,Inserm U1042, Laboratoire HP2 Hypoxie-Physiopathologies, Université Grenoble-Alpes, Grenoble, France
| | - Youri Yordanov
- Faculté de Médecine, Sorbonne Universités, 75013, Paris, France.,Inserm, U1153, Université Paris-Descartes, 75006, Paris, France.,Service des Urgences, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Pierre-Géraud Claret
- Pôle Anesthésie Réanimation Douleur Urgences, Centre Hospitalier Universitaire de Nîmes, 4, Rue du Professeur-Robert-Debré, 30029, Nîmes, France
| | - Naïke Bigé
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France
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20
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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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21
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Malerba E, Mazzarino M, Del Baldo F, Corradini S, Carotenuto G, Giunti M, Fracassi F. Use of lispro insulin for treatment of diabetic ketoacidosis in cats. J Feline Med Surg 2019; 21:115-123. [PMID: 29513157 PMCID: PMC10814606 DOI: 10.1177/1098612x18761696] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the efficacy and safety of lispro insulin for the treatment of feline diabetic ketoacidosis (DKA). Times to resolution of hyperglycaemia, ketosis and acidosis were compared between cats treated with continuous rate infusion (CRI) of lispro insulin and cats treated with CRI of regular insulin. METHODS Client-owned cats with naturally occurring DKA, newly diagnosed with diabetes mellitus (DM) or already receiving treatment for DM, were included. Diagnosis of DKA involved the presence of at least two clinical signs consistent with DKA (eg, polyuria/polydipsia, anorexia, severe lethargy, vomiting and dehydration), blood glucose (BG) concentration >13.9 mmol/l (>250 mg/dl), blood beta hydroxybutyrate (BHB) concentration >2.5 mmol/l and venous pH <7.3 or bicarbonate <15 mEq/l. Cats were treated with a standard protocol of an intravenous (IV) CRI of regular insulin (group R) or lispro insulin (group L). The time to resolution of DKA was defined as the time interval from when the IV CRI of insulin began until marked hyperglycaemia (BG >13.9 mmol/l [>250 mg/dl]), ketosis (BHB concentration >1 mmol/l) and acidosis (venous pH <7.3 and/or bicarbonate <15 mEq/l) resolved. RESULTS Eighteen DKA cases (nine per group) were enrolled into the study. There were no significant differences in the median time to resolution of three variables (hyperglycaemia, ketosis and acidosis) between the two groups. Two cats in group R developed hypoglycaemia during the CRI of insulin. One cat in group L and three cats in group R developed hypophosphataemia, which required phosphate supplementation. CONCLUSIONS AND RELEVANCE IV CRI of lispro insulin has few side effects and appears to be as effective as IV CRI of regular insulin in the treatment of cats with DKA.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Michela Mazzarino
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Francesca Del Baldo
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Sara Corradini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Gaia Carotenuto
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Massimo Giunti
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
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Gauntt J, Vaidyanathan P, Basu S. Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis. J Pediatr Endocrinol Metab 2019; 32:11-17. [PMID: 30530908 DOI: 10.1515/jpem-2018-0394] [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: 09/11/2018] [Accepted: 11/02/2018] [Indexed: 11/15/2022]
Abstract
Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children's hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.
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Affiliation(s)
- Jennifer Gauntt
- Division of Cardiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA, Phone: +614-722-0596
| | - Priya Vaidyanathan
- Division of Endocrinology and Diabetes, Children's National Health System, Washington, DC, USA
| | - Sonali Basu
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
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Razavi Z, Maher S, Fredmal J. Comparison of subcutaneous insulin aspart and intravenous regular insulin for the treatment of mild and moderate diabetic ketoacidosis in pediatric patients. Endocrine 2018; 61:267-274. [PMID: 29797212 DOI: 10.1007/s12020-018-1635-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the safety/efficacy of intermittent subcutaneous rapid-acting insulin aspart with the standard low-dose intravenous infusion protocol of regular insulin for treatment of pediatric diabetic-ketoacidosis. METHODS For a prospective randomized-controlled clinical trial on 50 children/adolescents with mild/moderate diabetic-ketoacidosis, the diagnostic criteria for ketoacidosis included: blood glucose level >250 mg/dl, ketonuria>++, venous pH <7.3 and/or bicarbonate <15 mEq/l. DATA COLLECTED age, sex, clinical/laboratory parameters including blood sugar, arterial blood gases, urine ketones, severity of diabetic-ketoacidosis, amount of insulin administered to correct acidosis, time to recover from diabetic-ketoacidosis, number of days of hospitalization, and complications. Patients were randomly assigned to intervention (subcutaneous) and control (intravenous) groups. Controls received 0.05-0.1 unit/kg/hour intravenous regular insulin infusion until resolution of diabetic-ketoacidosis and stayed in the intensive care unit. Interventions received 0.15 unit/kg subcutaneous insulin aspart every two hours and stayed in regular medical ward. RESULTS From 50 children (age 2-17 years), 56% (28) were females, and 48% (24) had established-type I diabetes. Intervention and control groups had similar baseline clinical/laboratory findings. Average age (years) was 8.6 ± 0.8 for intervention and 8.86 ± 0.7 for control group (p = 0.4) with 64% having moderate diabetic-ketoacidosis. The mean total-dose of insulin units needed for treatment of diabetic-ketoacidosis in intervention (subcutaneous insulin aspart) was lower than controls (intravenous regular insulin) (p < 0.001). No mortality/serious events happened. Three diabetic-ketoacidosis recurrences among interventions and one among controls occurred. CONCLUSIONS To manage mild/moderate diabetic-ketoacidosis in children/adolescents, subcutaneous rapid-acting insulin aspart is an alternative to intravenous infusion of regular insulin. Subcutaneous insulin treated moderate DKA with faster recovery/shorter hospital stay.
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Affiliation(s)
- Zahra Razavi
- Associate Professor, Pediatric Endocrinologist, Pediatrics Department, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran.
| | - Saba Maher
- Pediatric Senior Resident, Department of Pediatrics, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Javad Fredmal
- Associate Professor of Biostatistics, Hamedan University of Medical Sciences, Hamedan, Iran
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von Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. Diabetes Res Clin Pract 2018; 135:76-84. [PMID: 29111277 PMCID: PMC6013285 DOI: 10.1016/j.diabres.2017.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/22/2017] [Accepted: 09/18/2017] [Indexed: 01/21/2023]
Abstract
AIMS Data are sparse concerning use of serum electrolyte parameters as compared to venous blood gas (VBG) measurements to monitor acid-base status during treatment of diabetic ketoacidosis (DKA). We explored the utility of various parameters to define DKA resolution by investigating the relationship of venous pH (vpH), anion gap (AG), serum bicarbonate (HCO3), and glucose concentration during management of DKA in children with new onset diabetes mellitus (NODM). METHODS We included all patients with NODM presenting with DKA to Boston Children's Hospital from 10/1/07-7/1/13. DKA was defined as serum glucose ≥ 200 mg/dL (11.1 mmol/L) and vpH<7.30; severity as mild <7.30, moderate<7.20, severe<7.10; resolution of DKA as vpH≥7.30 and AG≤18 mmol/L. We used Cox regression to determine time to DKA resolution, and logistic regression to evaluate different serum HCO3 cut-off values as predictors of DKA resolution. RESULTS 263 patients (133F, mean age 9.9±4.4 years, 74% White) were included. DKA was mild in 134 (51%), moderate in 75 (28%) and severe in 54 (20%). In mild DKA, AG closed after normalization of vpH; in moderate and severe DKA, AG closed before normalization of vpH. HCO3>15mmol/L correlated with vpH≥7.30, and had 76% sensitivity and 85% specificity to predict DKA resolution. Median times to DKA resolution were similar using two different definitions: vpH and AG (8.4h [IQR 6.3-11.9]) vs. HCO3>15 mmol/L (7.9 h [IQR 5.0-11.8]), p=.42. CONCLUSIONS During management of pediatric DKA, HCO3 > 15 mmol/L reliably predicts resolution of DKA. In low-resource settings where VBG is unavailable, electrolyte parameters alone may be used to determine DKA resolution.
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Affiliation(s)
- Julia E von Oettingen
- Division of Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, QC H4A3J1, Canada; Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA.
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
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Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am 2017; 101:587-606. [PMID: 28372715 PMCID: PMC6535398 DOI: 10.1016/j.mcna.2016.12.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.
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Affiliation(s)
- Maya Fayfman
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA.
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Mendez Y, Surani S, Varon J. Diabetic ketoacidosis: Treatment in the intensive care unit or general medical/surgical ward? World J Diabetes 2017; 8:40-44. [PMID: 28265341 PMCID: PMC5320747 DOI: 10.4239/wjd.v8.i2.40] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/05/2016] [Accepted: 11/22/2016] [Indexed: 02/05/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is defined as an acute metabolic disorder, which is characterized by an increased presence of circulating ketones, and the development of ketoacidosis in the presence of hyperglycemia. This syndrome occurs as a result of insulin deficiency. Patients can be dramatically ill, however, with aggressive treatment, most patients recover rapidly. Despite being a low-risk condition, the development of acidosis, is one of the admission criteria to the intensive care unit (ICU) for these patients, in order to provide close monitoring, and recognize complications that could result from the use of aggressive therapy, such as continuous infusions if insulin. In some institutions, DKA is treated in the emergency department and general medical/surgical wards to avoid ICU overcrowding.
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Umpierrez G, Korytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol 2016; 12:222-32. [PMID: 26893262 DOI: 10.1038/nrendo.2016.15] [Citation(s) in RCA: 249] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopaenia and severe hyperglycaemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is <1%. Mortality among patients with HHS is ~10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age >60 years. The estimated annual cost of hospital treatment for patients experiencing hyperglycaemic crises in the USA exceeds US$2 billion. Hypoglycaemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycaemia are likely to experience a long duration of hospital stay and increased mortality. This Review describes the clinical presentation, precipitating causes, diagnosis and acute management of these diabetic emergencies, including a discussion of practical strategies for their prevention.
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Affiliation(s)
- Guillermo Umpierrez
- Division of Endocrinology and Metabolism, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, Georgia 30303, USA
| | - Mary Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh, 3601 Fifth Avenue, Suite 560, Pittsburgh, Pennsylvania 15213, USA
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Anzola I, Gomez PC, Umpierrez GE. Management of diabetic ketoacidosis and hyperglycemic hyperosmolar state in adults. Expert Rev Endocrinol Metab 2016; 11:177-185. [PMID: 30058870 DOI: 10.1586/17446651.2016.1145049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are two acute complications of diabetes associated with high mortality rate if not efficiently and effectively treated. Both entities are characterized by insulinopenia, hyperglycemia and dehydration. DKA and HHS are two serious complications of diabetes associated with significant mortality and a high healthcare costs. The overall DKA mortality in the US is less than 1%, but a rate higher than 5% is reported in the elderly and in patients with concomitant life-threatening illnesses. Mortality in patients with HHS is reported between 5% and 16%, which is about 10 times higher than the mortality in patients with DKA. Objectives of management include restoration circulatory volume and tissue perfusion, resolution of hyperglycemia, correction of electrolyte imbalance and increased ketogenesis.
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Affiliation(s)
- Isabel Anzola
- a Department of Medicine , Division of Endocrinology and Metabolism at Emory University , Atlanta , GA , USA
| | - Patricia C Gomez
- a Department of Medicine , Division of Endocrinology and Metabolism at Emory University , Atlanta , GA , USA
| | - Guillermo E Umpierrez
- a Department of Medicine , Division of Endocrinology and Metabolism at Emory University , Atlanta , GA , USA
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Andrade‐Castellanos CA, Colunga‐Lozano LE, Delgado‐Figueroa N, Gonzalez‐Padilla DA. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database Syst Rev 2016; 2016:CD011281. [PMID: 26798030 PMCID: PMC8829395 DOI: 10.1002/14651858.cd011281.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of uncontrolled diabetes that mainly occurs in individuals with autoimmune type 1 diabetes, but it is not uncommon in some people with type 2 diabetes. The treatment of DKA is traditionally accomplished by the administration of intravenous infusion of regular insulin that is initiated in the emergency department and continued in an intensive care unit or a high-dependency unit environment. It is unclear whether people with DKA should be treated with other treatment modalities such as subcutaneous rapid-acting insulin analogues. OBJECTIVES To assess the effects of subcutaneous rapid-acting insulin analogues for the treatment of diabetic ketoacidosis. SEARCH METHODS We identified eligible trials by searching MEDLINE, PubMed, EMBASE, LILACS, CINAHL, and the Cochrane Library. We searched the trials registers WHO ICTRP Search Portal and ClinicalTrials.gov. The date of last search for all databases was 27 October 2015. We also examined reference lists of included randomised controlled trials (RCTs) and systematic reviews, and contacted trial authors. SELECTION CRITERIA We included trials if they were RCTs comparing subcutaneous rapid-acting insulin analogues versus standard intravenous infusion in participants with DKA of any age or sex with type 1 or type 2 diabetes, and in pregnant women. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed studies for risk of bias, and evaluated overall study quality utilising the GRADE instrument. We assessed the statistical heterogeneity of included studies by visually inspecting forest plots and quantifying the diversity using the I² statistic. We synthesised data using random-effects model meta-analysis or descriptive analysis, as appropriate. MAIN RESULTS Five trials randomised 201 participants (110 participants to subcutaneous rapid-acting insulin analogues and 91 to intravenous regular insulin). The criteria for DKA were consistent with the American Diabetes Association criteria for mild or moderate DKA. The underlying cause of DKA was mostly poor compliance with diabetes therapy. Most trials did not report on type of diabetes. Younger diabetic participants and children were underrepresented in our included trials (one trial only). Four trials evaluated the effects of the rapid-acting insulin analogue lispro, and one the effects of the rapid-acting insulin analogue aspart. The mean follow-up period as measured by mean hospital stay ranged between two and seven days. Overall, risk of bias of the evaluated trials was unclear in many domains and high for performance bias for the outcome measure time to resolution of DKA.No deaths were reported in the included trials (186 participants; 3 trials; moderate- (insulin lispro) to low-quality evidence (insulin aspart)). There was very low-quality evidence to evaluate the effects of subcutaneous insulin lispro versus intravenous regular insulin on the time to resolution of DKA: mean difference (MD) 0.2 h (95% CI -1.7 to 2.1); P = 0.81; 90 participants; 2 trials. In one trial involving children with DKA, the time to reach a glucose level of 250 mg/dL was similar between insulin lispro and intravenous regular insulin. There was very low-quality evidence to evaluate the effects of subcutaneous insulin aspart versus intravenous regular insulin on the time to resolution of DKA: MD -1 h (95% CI -3.2 to 1.2); P = 0.36; 30 participants; 1 trial. There was low-quality evidence to evaluate the effects of subcutaneous rapid-acting insulin analogues versus intravenous regular insulin on hypoglycaemic episodes: 6 of 80 insulin lispro-treated participants compared with 9 of 76 regular insulin-treated participants reported hypoglycaemic events; risk ratio (RR) 0.59 (95% CI 0.23 to 1.52); P = 0.28; 156 participants; 4 trials. For insulin aspart compared with regular insulin, RR for hypoglycaemic episodes was 1.00 (95% CI 0.07 to 14.55); P = 1.0; 30 participants; 1 trial; low-quality evidence. Socioeconomic effects as measured by length of mean hospital stay for insulin lispro compared with regular insulin showed a MD of -0.4 days (95% CI -1 to 0.2); P = 0.22; 90 participants; 2 trials; low-quality evidence and for insulin aspart compared with regular insulin 1.1 days (95% CI -3.3 to 1.1); P = 0.32; low-quality evidence. Data on morbidity were limited, but no specific events were reported for the comparison of insulin lispro with regular insulin. No trial reported on adverse events other than hypoglycaemic episodes, and no trial investigated patient satisfaction. AUTHORS' CONCLUSIONS Our review, which provided mainly data on adults, suggests on the basis of mostly low- to very low-quality evidence that there are neither advantages nor disadvantages when comparing the effects of subcutaneous rapid-acting insulin analogues versus intravenous regular insulin for treating mild or moderate DKA.
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Affiliation(s)
- Carlos A Andrade‐Castellanos
- Hospital Civil de Guadalajara "Dr. Juan I. Menchaca"Department of Emergency MedicineSalvador Quevedo y Zubieta No. 750GuadalajaraJaliscoMexico44340
| | - Luis Enrique Colunga‐Lozano
- Hospital Civil de Guadalajara "Fray Antonio Alcalde"Department of Critical Care MedicineCalle Coronel Calderón #777GuadalajaraGuadalajaraMexico44320
| | - Netzahualpilli Delgado‐Figueroa
- Hospital Civil de Guadalajara Dr. Juan I. MenchacaDepartment of PediatricsSalvador Quevedo y Zubieta No. 750GuadalajaraJaliscoMexico44340
| | - Daniel A Gonzalez‐Padilla
- Hospital Universitario 12 de OctubreDepartment of UrologyAvenida de Córdoba, s/nMadridMadridSpain28041
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Singh K, Ansari MT, Patel RV, Bedard M, Keely E, Tierney M, Moher D. Comparative efficacy and safety of insulin analogs in hospitalized adults. Am J Health Syst Pharm 2015; 72:525-35. [PMID: 25788506 DOI: 10.2146/ajhp140161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The comparative efficacy, safety, and cost-effectiveness of rapid and long-acting insulin analogs compared with regular or neutral protamine Hagedorn nonanalog insulins or with oral antidiabetic agents in hospitalized adults were evaluated. METHODS A literature search was conducted to identify studies that compared the effects of rapid-acting, long-acting, or mixed insulin analogs with short- or intermediate-acting insulin or any other oral antidiabetic medication. RESULTS Twenty-three primary studies were included in the review. Rapid-acting analogs and basal-bolus analog regimens were found to reduce the duration of hospital stay by approximately one day compared with regular insulin and basal-bolus nonanalog regimens. One large cohort study found an adjusted 48% relative risk reduction in mortality with rapid-acting analogs versus regular insulin in a heterogeneous hospitalized hyperglycemic population. A randomized controlled trial found a significant reduction in postoperative complications with basal-bolus analogs compared with basal-bolus nonanalog insulin. When compared with regular sliding-scale insulin (SSI), fixed-dose insulin glargine with or without insulin glulisine was found to reduce the blood glucose concentration in patients with type 2 diabetes and reduce postoperative complications in surgical patients with diabetes. The quality of evidence was primarily very low or low for most outcomes. CONCLUSION A systematic literature review revealed a very low or low quality of evidence, suggesting that, compared with nonanalog regimens, rapid-acting insulin analogs reduce the duration of hospital stay and mortality rates and that basal- bolus analog regimens may reduce the duration of hospital stay and postoperative complications. There is also a low quality of evidence to suggest that a fixed-dose analog regimen of insulin glargine with or without insulin glulisine is more effective than regular SSI for reducing blood glucose concentrations and postoperative complications.
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Affiliation(s)
- Kavita Singh
- Kavita Singh, B.Sc.Phm., M.P.H., is Ph.D. Student, University of Ottawa, Ontario, Canada. Mohammed T. Ansari, M.B.B.S., M.Med. Sc., M.Phil., is Associate Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, and Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa. Rakesh V. Patel, M.D. Pharm.D., is Director, Adult Critical Care Medicine Training Program, University of Ottawa, and Staff Intensivist, The Ottawa Hospital. Mario Bedard, B.Pharm., Pharm.D., is Director of Pharmacy, The Ottawa Hospital, Ottawa. Erin Keely, M.D., FRCPC, is Chief, Division of Endocrinology and Metabolism, The Ottawa Hospital, and Professor, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa. Mike Tierney, B.Sc.Phm., M.Sc., is Vice President, Clinical Programs, The Ottawa Hospital. David Moher, Ph.D., is Senior Scientist, Ottawa Hospital Research Institute.
| | - Mohammed T Ansari
- Kavita Singh, B.Sc.Phm., M.P.H., is Ph.D. Student, University of Ottawa, Ontario, Canada. Mohammed T. Ansari, M.B.B.S., M.Med. Sc., M.Phil., is Associate Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, and Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa. Rakesh V. Patel, M.D. Pharm.D., is Director, Adult Critical Care Medicine Training Program, University of Ottawa, and Staff Intensivist, The Ottawa Hospital. Mario Bedard, B.Pharm., Pharm.D., is Director of Pharmacy, The Ottawa Hospital, Ottawa. Erin Keely, M.D., FRCPC, is Chief, Division of Endocrinology and Metabolism, The Ottawa Hospital, and Professor, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa. Mike Tierney, B.Sc.Phm., M.Sc., is Vice President, Clinical Programs, The Ottawa Hospital. David Moher, Ph.D., is Senior Scientist, Ottawa Hospital Research Institute
| | - Rakesh V Patel
- Kavita Singh, B.Sc.Phm., M.P.H., is Ph.D. Student, University of Ottawa, Ontario, Canada. Mohammed T. Ansari, M.B.B.S., M.Med. Sc., M.Phil., is Associate Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, and Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa. Rakesh V. Patel, M.D. Pharm.D., is Director, Adult Critical Care Medicine Training Program, University of Ottawa, and Staff Intensivist, The Ottawa Hospital. Mario Bedard, B.Pharm., Pharm.D., is Director of Pharmacy, The Ottawa Hospital, Ottawa. Erin Keely, M.D., FRCPC, is Chief, Division of Endocrinology and Metabolism, The Ottawa Hospital, and Professor, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa. Mike Tierney, B.Sc.Phm., M.Sc., is Vice President, Clinical Programs, The Ottawa Hospital. David Moher, Ph.D., is Senior Scientist, Ottawa Hospital Research Institute
| | - Mario Bedard
- Kavita Singh, B.Sc.Phm., M.P.H., is Ph.D. Student, University of Ottawa, Ontario, Canada. Mohammed T. Ansari, M.B.B.S., M.Med. Sc., M.Phil., is Associate Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, and Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa. Rakesh V. Patel, M.D. Pharm.D., is Director, Adult Critical Care Medicine Training Program, University of Ottawa, and Staff Intensivist, The Ottawa Hospital. Mario Bedard, B.Pharm., Pharm.D., is Director of Pharmacy, The Ottawa Hospital, Ottawa. Erin Keely, M.D., FRCPC, is Chief, Division of Endocrinology and Metabolism, The Ottawa Hospital, and Professor, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa. Mike Tierney, B.Sc.Phm., M.Sc., is Vice President, Clinical Programs, The Ottawa Hospital. David Moher, Ph.D., is Senior Scientist, Ottawa Hospital Research Institute
| | - Erin Keely
- Kavita Singh, B.Sc.Phm., M.P.H., is Ph.D. Student, University of Ottawa, Ontario, Canada. Mohammed T. Ansari, M.B.B.S., M.Med. Sc., M.Phil., is Associate Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, and Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa. Rakesh V. Patel, M.D. Pharm.D., is Director, Adult Critical Care Medicine Training Program, University of Ottawa, and Staff Intensivist, The Ottawa Hospital. Mario Bedard, B.Pharm., Pharm.D., is Director of Pharmacy, The Ottawa Hospital, Ottawa. Erin Keely, M.D., FRCPC, is Chief, Division of Endocrinology and Metabolism, The Ottawa Hospital, and Professor, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa. Mike Tierney, B.Sc.Phm., M.Sc., is Vice President, Clinical Programs, The Ottawa Hospital. David Moher, Ph.D., is Senior Scientist, Ottawa Hospital Research Institute
| | - Mike Tierney
- Kavita Singh, B.Sc.Phm., M.P.H., is Ph.D. Student, University of Ottawa, Ontario, Canada. Mohammed T. Ansari, M.B.B.S., M.Med. Sc., M.Phil., is Associate Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, and Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa. Rakesh V. Patel, M.D. Pharm.D., is Director, Adult Critical Care Medicine Training Program, University of Ottawa, and Staff Intensivist, The Ottawa Hospital. Mario Bedard, B.Pharm., Pharm.D., is Director of Pharmacy, The Ottawa Hospital, Ottawa. Erin Keely, M.D., FRCPC, is Chief, Division of Endocrinology and Metabolism, The Ottawa Hospital, and Professor, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa. Mike Tierney, B.Sc.Phm., M.Sc., is Vice President, Clinical Programs, The Ottawa Hospital. David Moher, Ph.D., is Senior Scientist, Ottawa Hospital Research Institute
| | - David Moher
- Kavita Singh, B.Sc.Phm., M.P.H., is Ph.D. Student, University of Ottawa, Ontario, Canada. Mohammed T. Ansari, M.B.B.S., M.Med. Sc., M.Phil., is Associate Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, and Adjunct Professor, Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa. Rakesh V. Patel, M.D. Pharm.D., is Director, Adult Critical Care Medicine Training Program, University of Ottawa, and Staff Intensivist, The Ottawa Hospital. Mario Bedard, B.Pharm., Pharm.D., is Director of Pharmacy, The Ottawa Hospital, Ottawa. Erin Keely, M.D., FRCPC, is Chief, Division of Endocrinology and Metabolism, The Ottawa Hospital, and Professor, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa. Mike Tierney, B.Sc.Phm., M.Sc., is Vice President, Clinical Programs, The Ottawa Hospital. David Moher, Ph.D., is Senior Scientist, Ottawa Hospital Research Institute
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Cohn BG, Keim SM, Watkins JW, Camargo CA. Does Management of Diabetic Ketoacidosis with Subcutaneous Rapid-acting Insulin Reduce the Need for Intensive Care Unit Admission? J Emerg Med 2015; 49:530-8. [PMID: 26238182 DOI: 10.1016/j.jemermed.2015.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/21/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND In the last 20 years, rapid-acting insulin analogs have emerged on the market, including aspart and lispro, which may be efficacious in the management of diabetic ketoacidosis (DKA) when administered by non-intravenous (i.v.) routes. CLINICAL QUESTION In patients with mild-to-moderate DKA without another reason for intensive care unit (ICU) admission, is the administration of a subcutaneous (s.c.) rapid-acting insulin analog a safe and effective alternative to a continuous infusion of i.v. regular insulin, and would such a strategy eliminate the need for ICU admission? EVIDENCE REVIEW Five randomized controlled trials were identified and critically appraised. RESULTS The outcomes suggest that there is no difference in the duration of therapy required to resolve DKA with either strategy. CONCLUSION Current evidence supports DKA management with s.c. rapid-acting insulin analogs in a non-ICU setting in carefully selected patients.
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Affiliation(s)
- Brian G Cohn
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Samuel M Keim
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, Arizona
| | - Joseph W Watkins
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Carlos A Camargo
- Departments of Emergency Medicine and Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
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Mul D, Molendijk E. Question 1: Treatment of mild to moderate ketoacidosis in children and adolescents with subcutaneous insulin. Arch Dis Child 2015; 100:106-8. [PMID: 25294890 DOI: 10.1136/archdischild-2014-307238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- D Mul
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
| | - Eva Molendijk
- HagaZiekenhuis/Juliana Children's Hospital, The Hague, The Netherlands
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Abstract
Ward management of diabetic ketoacidosis (DKA) using subcutaneous insulin in specific patient populations is safe and effective, but insulin administered by continuous infusion has not been analyzed in this setting. This retrospective cohort study utilizing a nursing-driven, continuous infusion insulin calculator demonstrated safe and effective treatment of patients with DKA on medicine wards.
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Vincent M, Nobécourt E. Treatment of diabetic ketoacidosis with subcutaneous insulin lispro: a review of the current evidence from clinical studies. DIABETES & METABOLISM 2013; 39:299-305. [PMID: 23642642 DOI: 10.1016/j.diabet.2012.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/05/2012] [Accepted: 12/10/2012] [Indexed: 12/23/2022]
Abstract
AIM Low-dose intravenous infusions of regular insulin, usually initiated in the emergency department and continued in the intensive care unit (ICU), are the standard care for patients with diabetic ketoacidosis (DKA) to ensure rapid resolution of hyperglycaemia and ketoacidosis. Several studies have evaluated whether subcutaneous injections of the rapid-acting analogue insulin lispro may be an alternative to intravenous insulin infusion for avoiding ICU admissions of uncomplicated DKA cases. METHODS This review summarizes the current clinical evidence for the effectiveness and safety of subcutaneous insulin lispro injections in non-severe DKA patients. Relevant studies were identified by a systematic literature search through the PubMed database. RESULTS To date, four small randomized studies (156 patients overall; three studies in adults and one in paediatric patients with diabetes) have directly compared subcutaneous insulin lispro injections every 1-2h vs continuous intravenous infusions of regular insulin. Patients with severe complications were excluded. In all studies, the mean time to resolution of DKA was similar in both treatment groups [range (three studies): lispro 10-14.8h; regular insulin 11-13.2h]. The mean time to resolution of hyperglycaemia, total insulin doses required, number of hospitalization days and number of hypoglycaemic episodes were similar in both treatment groups; no severe complications or DKA recurrences were reported, and one study showed a 39% cost reduction for the insulin lispro group. CONCLUSION In patients with mild-to-moderate DKA, subcutaneous injections of insulin lispro every 1-2h offer a feasible alternative to continuous intravenous infusions of regular insulin, and should now be evaluated in larger, more appropriately powered studies.
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Affiliation(s)
- M Vincent
- Medical - Diabetes, Lilly France, Suresnes, France
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