Treatment Of Diabetic Ketoacidosis Research Articles

IMPLEMENTATION AND OUTCOME OF A PROTOCOL-BASED TREATMENT FOR DIABETIC KETOACIDOSIS IN A TERTIARY CARE PEDIATRIC EMERGENCY DEPARTMENT

BackgroundThe standardization of clinical practice in emergency treatment of diabetic ketoacidosis (DKA) is a prerequisite for improving patient care. For this purpose, a standardized DKA protocol incorporating a two-bag system has been implemented since January 2020 in our center. ObjectivesTo assess the impact of the development and utilization of the standard treatment pathway for DKA on patient outcomes. MethodsThis retrospective cohort study involved patients diagnosed with DKA and admitted to the pediatric emergency department (PED). The entire period of the study was from January 2017 to September 2022. Patients with DKA managed before and after implementation of the protocol were compared in terms of clinical outcomes. ResultsOut of 145 patients, 77 (53%) patients were in the pre-protocol group, 68 (47%) were in the protocol group. Age, sex, and severity of DKA were similar between the groups. Implementation of the protocol resulted in shorter resolution time of acidosis and ketosis (p = 0.007, p < 0.001, respectively), higher correction rates of bicarbonate and blood ketones (p = 0.003, p < 0.001, respectively), shorter duration of IV insulin treatment (p = 0.008), more appropriate potassium dosage administrating to IV fluids (p < 0.001), lower incidence of hypokalemia, hypophosphatemia, and hypoglycemia (p = 0.008, p = 0.002, p = 0.036, respectively), and smaller number of IV bags use (p < 0.001). ConclusionImplementation of a protocol-based pathway for DKA involving a two-bag system provided earlier correction of ketoacidosis, decreased the risk of complications, and reduced resource utilization in the PED.

"TRATAMENTO DA CETOACIDOSE DIABÉTICA NA UNIDADE DE TERAPIA INTENSIVA"

Introduction: Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes caused by a lack of insulin, leading to hyperglycemia and acidosis. Factors such as infections and poor insulin administration can trigger it, and its urgent treatment in the ICU involves fluid replacement, intravenous insulin, and control of complications. Methodology: This article is a literature review on the treatment of diabetic ketoacidosis in the ICU, based on studies from the last 10 years available in English and Portuguese in the PubMed, SciELO, and BVS databases. Complete and free articles were included, excluding those that did not directly address the topic. Results and Discussion: The treatment of diabetic ketoacidosis (DKA) in the ICU follows protocols to quickly correct metabolic and hemodynamic alterations. Initial replacement of isotonic fluids treats severe dehydration and improves tissue perfusion. Low-dose intravenous insulin corrects ketosis and hyperglycemia, but should be adjusted accordingly, with potassium levels also need to be monitored and replaced. Continuous monitoring of blood glucose and electrolytes is crucial to avoid complications such as cerebral edema. Identifying and treating the underlying cause of DKA, such as infections, is essential to prevent recurrences. Conclusion: The treatment of diabetic ketoacidosis in the ICU is mainly based on rapid fluid replacement, controlled insulin administration, and continuous monitoring. Potassium management and identification of the cause are essential to prevent recurrences and improve prognosis, with the ICU being the ideal setting for intensive care and reducing mortality.

Use of a two-bag fluid administration protocol in the treatment of paediatric diabetic ketoacidosis: A retrospective review

ABSTRACT Objectives The ‘two-bag method’ for the treatment of diabetic ketoacidosis (DKA) uses two intravenous fluid bags, only one of which contains 10% dextrose. The bags are run concurrently with rates adjusted according to a rate change table to allow the relative amount of dextrose administered to be adjusted over time, without the need for bag replacements. The Children’s Hospital at London Health Sciences Centre (CHLHSC) two-bag protocol is a simplified version of that used by other centres. The objective of this study was to ensure implementation of the CHLHSC two-bag protocol continues to provide safe and effective treatment of paediatric DKA and decreases resource utilization. Methods This retrospective chart review compared treatment pre- and post-protocol implementation. Results A total of 22 admissions were included. No significant differences in efficacy or safety outcomes were found between the protocol groups. There was no statistically significant difference between the two and one-bag protocols in time to normalization of serum bicarbonate (13.80 ± 7.68 versus 15.01 ± 7.53 h, P = 0.714), blood glucose correction (8.75 ± 4.86 versus 11.85 ± 4.92 h, P = 0.152), and critical care unit length of stay (24.26 ± 9.94 versus 32.30 ± 13.36, P = 0.399). The nursing staff appeared to appropriately implement the rate change table, but the chart documentation was poor. Conclusions The CHLHSC simplified two-bag protocol provides a safe and effective alternative to the one-bag protocol for DKA correction in paediatric patients and may also result in decreased resource utilization.

6844 Comparison of Lactated Ringers and Normal Saline in the Treatment of Diabetic Ketoacidosis

Abstract Disclosure: J.N. Johnson: None. A.T. Drincic: None. K. Nein: None. E. Buddenhagen: None. K. Samson: None. T. Langenhan: None. Background: Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. We hypothesized that the use of LR compared to NS for volume management in DKA will shorten time to DKA resolution, reduce time to DKA associated protocol insulin infusion discontinuation, and result in lower post-intravenous fluid resuscitation chloride values. Methods: We conducted a single institution, retrospective cohort study of patients admitted with the diagnosis of DKA following our institution’s transition from NS to lactated ringers (LR) as the default resuscitative and maintenance fluid in our DKA management protocol. Adult patients admitted with DKA before and after the protocol change were identified. The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol continuous insulin infusion. Results: Of 246 patients meeting inclusion criteria, 119 were stratified to the NS group (pre-protocol change) and 127 to the LR group (post-protocol change). T-test analysis revealed decreased time to DKA resolution in the LR group (mean 17.1 hours; SD 11.02) relative to the NS group (mean 20.6 hours; SD 12.22; p = .02). Duration of DKA protocol continuous intravenous insulin was shorter in the LR group (mean 16.0 hours; SD 8.72) compared to the NS group (mean 21.4 hours; SD 12.50; p = 0.0001). Conclusions: In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol continuous insulin infusion. Presentation: 6/2/2024

Balanced Fluids Versus Normal Saline for Initial Fluid Resuscitation in Adults With Diabetic Ketoacidosis.

Background: Normal saline (NS) has been the choice fluid for volume resuscitation in diabetic ketoacidosis (DKA) for decades. Large volume resuscitation with NS can lead to hyperchloremic metabolic acidosis and is associated with a higher incidence of major adverse kidney events compared to balanced fluids (BF). Objective: Compare safety and effectiveness of fluid resuscitation with BF vs NS in adult patients with DKA. Methods: Single-center retrospective cohort study evaluated patients who received NS or BF for DKA treatment between July 2020 and August 2021. Primary endpoint was time to DKA resolution. Secondary endpoints included time to anion gap ≤12, HCO3 ≥15 and ≥18mmol/L, acute kidney injury, and hospital and intensive care unit length of stay. Results: 110 patients were included (NS 55% (n = 60), BF 45% (n = 50)). Time to DKA resolution was faster in patients who received BF vs NS (13 (10 - 19) hours vs 17 (11 - 25) hours, P = 0.02). Treatment with NS was associated with a longer time to resolution of DKA when adjusted for initial bicarbonate and AKI at admission. Conclusion: BF was associated with a shorter time to DKA resolution compared to NS.

Is there a relationship between hyperchloremia status and the risk of developing acute kidney injury in pediatric patients with diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Prerenal acute kidney injury (AKI) is associated with profound hypovolemia and reduced renal perfusion. Results regarding hyperchloremia-associated AKI in patients with DKA are conflicting; we therefore investigated the potential relationship between hyperchloremia status and the risk of developing AKI. This single-center cohort study included 113 newly diagnosed T1DM patients with DKA admitted to the pediatric intensive care unit. Laboratory parameters, including Na, K, urea, creatinine, and chloride levels, were retrospectively reviewed at the time of presentation and at 12, 24 and 36h. AKI was defined using the eGFR according to the pediatric RIFLE classification criteria. Twenty-two (19.5%) of the 113 patients were in the AKI group. Two-way repeated-measures ANOVA showed significant (P values ≤ 0.01) time interaction effects within the groups based on the eGFR and the serum chloride, hyperchloremia, and phosphate levels. Serum chloride levels did not differ between the groups during the first 12h (p > 0.05) but were significantly greater in the AKI group than in the non-AKI group at 24h and 36h (p < 0.01). The final DKA resolution time was significantly greater in the AKI group than in the non-AKI group [22.2 (9.5) vs. 17.0 (12.0) h, respectively; p = 0.03]. However, the groups had similar lengths of hospital stay [13.0 (8.0) days vs. 12.0 (4.0) days, respectively; p = 0.17].Conclusions: Hyperchloremia may be iatrogenic rather than causative during treatment. This may worsen renal failure and prolong the recovery and treatment time for DKA patients. What is Known? • Acute kidney injury resulting from severe volume depletion is a common occurrence in diabetic ketoacidosis and typically requires significant volume replacement therapy. • In recent years, hyperchloremia has been associated with increased risks of AKI, morbidity, and mortality in some conditions, such as diabetic ketoacidosis. What is New? • The incidence of hyperchloremia increases over time during the treatment of diabetic ketoacidosis. • Hyperchloremia may be an iatrogenic element rather than a cause of acute kidney injury during the treatment of diabetic ketoacidosis.

Management of diabetes-related hyperglycaemic emergencies in advanced chronic kidney disease: Review of the literature and recommendations.

Despite the substantial progress in the management of diabetes mellitus (DM), chronic kidney disease (CKD) remains one of the most common complications. Although uncommon, diabetic emergencies [diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS)] can still occur in stage 4 and 5 CKD, at times with less typical clinical manifestations due to the altered pathophysiology, presence of chronic metabolic acidosis and effect of haemodialysis on glycaemic control and metabolic parameters. The purpose of this article is to review the current literature and provide recommendations for the diagnosis and treatment of DKA, euglycaemic DKA and HHS in people with advanced CKD. Guidance on the management of diabetes-related emergencies mainly focuses on individuals with preserved renal function or early-stage CKD. Existing literature is limited, and recommendations are based on expert opinions and case reports. Given the clinical need for amended guidelines for this population, we are proposing a management algorithm for DKA and HHS based on clinical and metabolic parameters. In this review article, we propose treatment algorithms for diabetes-related hyperglycaemic emergencies in people with advanced CKD. Further research is needed to validate our proposed algorithms.

The Effects of Subcutaneous Rapid-Acting Insulin Aspart in the Treatment of Mild and Moderate Diabetic Ketoacidosis in Children: A Prospective Study.

Background and objectives The traditional treatment approach to diabetic ketoacidosis (DKA) involves the replacement of fluid and electrolyte deficits and a continuous intravenous infusion of regular insulin. Several clinical trials supported the administration of subcutaneous rapid-acting insulin analogs in the management of uncomplicated DKA. This study aimed to determine the effects/safety of subcutaneous rapid-acting insulin aspart injections in treating uncomplicated mild and moderate DKA in children. Methods In this prospective study in 2022, 25 children with mild/or moderate DKA were enrolled. The main outcome measure was median time (hours) for the resolution of ketoacidosis. Data recorded were as follows: clinical characteristics, severity of ketoacidosis and dehydration, blood glucose, sodium, potassium, creatinine, urine ketones, hospitalization's duration, and complications. Based on the degree of dehydration, fluid deficit was replaced by sodium chloride 0.45%. Insulin aspart 0.15 units/kg subcutaneous injections were given every 2 hours in the hospital outside ICU. Blood glucose was measured hourly and blood gases every 2 hours. Ketoacidosis was considered resolved when the patient did not have nausea/vomiting, was conscious, and could eat, and blood glucose was <250 mg/dL, pH was >7.30, and/or HCO3 was >15 mmol/L. Results Of 25 DKA patients (mean age 11.06±3.89, range 4-17 years, 60% girls), 16 cases (64%) had established type 1 diabetes. Overall, 13 (52%) cases had mild ketoacidosis (average pH=7.25), and 12 (48%) cases had moderate ketoacidosis (average pH=7.15). The mean time to resolution of ketoacidosis was 11.24 hours. All but one patient met DKA recovery criteria without complications. Mild cases compared to moderate cases of DKA had a shorter duration to resolution of DKA (p = 0.04). Mean duration of hospitalization was 2.3 days. No electrolyte disturbances, hypoglycemia events, readmission or mortality, or other adverse effects were observed. Conclusion In children with mild and moderate DKA, subcutaneous rapid-acting insulin aspart administration was an effective, safe, and convenient treatment.

Hyperglycaemic crises in adults with diabetes: a consensus report

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

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report.

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

Analysis of the 2-Bag Method for the Management of Diabetic Ketoacidosis: A Retrospective before and after Study.

Purpose: This study aims to assess the efficacy and safety of a two-bag method compared with a one-bag method for the treatment of diabetic ketoacidosis (DKA). We hypothesize that a two-bag method will decrease the incidence of hypoglycemia, when compared with a one-bag method. Methods: A retrospective chart review was conducted on patients treated for DKA at a Trinity Health institution between 2020 and 2022. A total of 1084 adult patients were included. Patients treated with the one-bag protocol were included in the pre-group, while those treated with the two-bag protocol were included in the post-group. The primary outcome was incidence of hypoglycemia (blood glucose <70mg/dL). Secondary outcomes included time to anion gap closure, insulin infusion duration, time to HCO3 correction, and incidence of hypokalemia. Patients were excluded if they were pregnant or diagnosed with Hyperosmolar Hyperglycemic State (HHS), euglycemic DKA, or ketosis from other causes. Results: The incidence of hypoglycemia was 38% in the pre-group and 15.83% in the post-group (P < .001). Patients in the pre-group were on an insulin infusion longer than the post-group (28.37hours vs 22.17hours, P < .001). Patients in the pre-group had a slower time to anion gap closure (8.99 hours vs 8.52hours, P = .021) and had a slower time to HCO3 correction (10.88hours vs 10.69hours, P = .004). Between-group incidence of hypokalemia was similar (66.39% vs 60%, P = .079). Conclusions: The two-bag method for the treatment of DKA resulted in improved safety and efficacy outcomes, compared with the one-bag method.

Outcomes of a tele-intensive care unit pharmacist on the management of diabetic ketoacidosis.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The tele-intensive care unit (tele-ICU) pharmacist facilitates patient-specific diabetic ketoacidosis (DKA) treatment utilizing guideline-directed therapy. This study was designed to determine how patient-specific interventions by a tele-ICU pharmacist affected patients with DKA compared to the standard of care. This retrospective cohort study utilized custom reports and manual chart review to evaluate the electronic health records of patients 18 years or older who received continuous intravenous insulin and were admitted for DKA between January 2019 and December 2020. The primary endpoint was time to DKA resolution, defined by the patient meeting at least 2 of the following criteria: a serum bicarbonate concentration of at least 18 mEq/L, an arterial pH of greater than 7.3, and closure of the anion gap (less than or equal to 12 mEq/L). Patients treated with tele-ICU pharmacist patient-specific interventions reached DKA resolution 7.32 hours earlier than patients treated with the standard of care (22.16 vs 29.48 hours; P = 0.0019). There was no statistically significant difference between the groups for ICU length of stay, time until subcutaneous insulin administration, incidence of hypoglycemia, incidence of severe hypoglycemia, and sodium bicarbonate use. In patients who received a tele-ICU pharmacist intervention, there was a statistically significant increase in the volume for fluid resuscitation and the amount of total continuous insulin infused after ICU admission and a statistically significant reduction in the time between laboratory draws. Treatment of patients with tele-ICU pharmacist patient-specific interventions was associated with faster DKA resolution, more frequent laboratory monitoring, and a higher volume of insulin and fluids infused than in patients treated with protocol-driven therapy.

Beta-Hydroxybutyrate Levels and Risk of Diabetic Ketoacidosis in Adults with Type 1 Diabetes Treated with Sotagliflozin.

Introduction: Sodium glucose cotransporter inhibitors may increase beta-hydroxybutyrate (BHB) in insulin-requiring patients. We determined factors associated with BHB changes from baseline (ΔBHB) and diabetic ketoacidosis (DKA) in patients with type 1 diabetes (T1D) receiving sotagliflozin as an insulin adjunct. Research Design and Methods: This post hoc analysis compared ΔBHB levels in adults with T1D receiving sotagliflozin 400 mg or placebo for 6 months. We evaluated clinical and metabolic factors associated with ΔBHB and used logistic regression models to determine predictors associated with BHB values >0.6 and >1.5 mmol/L (inTandem3 population; N = 1402) or with DKA events in a pooled analysis (inTandem1-3; N = 2453). Results: From baseline (median, 0.13 mmol/L), median fasting BHB increased by 0.04 mmol/L (95% confidence interval, 0.03-0.05; P < 0.001) at 24 weeks with sotagliflozin versus placebo; 67% of patients had no or minimal changes in BHB over time. Factors associated with on-treatment BHB >0.6 or >1.5 mmol/L included baseline BHB and sotagliflozin use. Age, insulin pump use, sotagliflozin use, baseline BHB, and ΔBHB were significantly associated with DKA episodes. Independent of treatment, DKA risk increased by 18% with each 0.1-mmol/L increase in baseline BHB and by 8% with each 0.1-mmol/L increase from baseline. Conclusion: Incremental increases in baseline BHB and ΔBHB were associated with a higher DKA risk independent of treatment. Adding sotagliflozin to insulin increased median BHB over 24 weeks in patients with T1D and was associated with increased DKA events. These results highlight the importance of BHB testing and monitoring and individualizing patient education on DKA risk, mitigation, identification, and treatment.

Diagnosis and Intensive Care in Children’s Diabetic Acidosis: an Interdisciplinary Viewpoint

Diabetic ketoacidosis (DKA) is the main cause of death and disability in children with type I diabetes mellitus (T1DM). Children’s mortality from T1DM reaches 1% in developed countries and 13% in developing countries. The main cause of death in DKA is cerebral edema, clinical manifestations of which develop in 0.5–0.9% of children with DKA, while mortality riches 24%.Objective. Developing recommendations to prevent life-threatening complications of children with DKA using analysis of literature data and consolidated opinion of experts on the issues of intensive care in children with T1DM.Materials and methods. We analyzed and discussed studies in diagnosis and treatment of DKA in children with type 1 diabetes and 1200 literature sources since January 1970, published in Russian peer-reviewed scientific journals and international publications presented in the online repository Medline (Pubmed). The search for publications was carried out using the keywords: «children», «DKA», «DM1», «dehydration», «cerebral edema».Results. We considered issues of epidemiology, pathogenesis, clinical manifestations, diagnosis, intensive care for DKA, as well as clinical and diagnosis, treatment, prevention of cerebral edema issues in children. Limitations of the study were the small number of modern studies with a high level of evidence (randomized controlled trials, meta-analyses) over the past 5 years on DKA in children.Conclusion. Taking into account the national and international experience, joint recommendations on a consensus format were developed and formulated for the diagnosis of DKA, its leading complications and treatment recommendations for children with T1DM and DKA. Timely and accurate diagnosis of DKA, intensive therapy options based on proven therapeutic efficacy, laboratory and clinical monitoring are warranted to interrupt the DKA pathogenesis, prevent the development of life-threatening conditions, and improve treatment outcomes for children with DKA.

Effectiveness of a standardized scenario in teaching the management of pediatric diabetic ketoacidosis (DKA) to residents: a simulation cross-sectional study

BackgroundDiabetic ketoacidosis (DKA) is a frequent manifestation at the onset of type 1 diabetes mellitus in children, possibly associated with a wide range of complications, often as a consequence of wrong or delayed treatment. Due to its complex and risky management, direct exposure to real situations alone is not sufficient to achieve adequate skills in pediatric DKA for residents. Simulation could be a valuable aid, allowing to practice a standardized scenario of a complex real-world situation. We aimed to test the effectiveness of a standardized scenario of pediatric DKA in teaching its recognition and treatment.MethodsWe develop a standardized scenario able to guide step-by-step the learners through the flowchart of DKA management and considering alternative evolutions in the case of possible deviations from guidelines. It was a real-life simulation with the use of a high-fidelity pediatric simulator. It was played by 78 pediatrics 20 and emergency medicine residents. At the end of the simulation, a validated questionnaire was administered to collect feedback from participants regarding the impact of the simulation on learning. All materials to reproduce the DKA scenario are provided.ResultsOverall, the scenario was rated as realistic (mean score 4.37 ± 0.68, from 1 to 5) and relevant to professional training (4.72 ± 0.47), useful in increasing confidence in interpreting laboratory tests (3.97 ± 0.65), group organization and communication strategies (3.49 ± 0.94), and managing the treatment of DKA (3.46 ± 0.92).ConclusionsThe use of a standardized scenario of pediatric DKA may be a valid tool to reinforce theoretical knowledge in residents, both in pediatrics and in emergency medicine, and to directly and safely practice pediatric DKA management.

An Overview on Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitors Induced Euglycemic Diabetic Ketoacidosis: Clinical Manifestation, Mechanism, Diagnosis, Prevention and Treatment

Euglycemic diabetic ketoacidosis is a transient and dangerous metabolic condition characterized by ketoacidosis and considerably lower blood glucose levels which is associated with the usage of newer class of oral antidiabetic medication known as Sodium-glucose cotransporter 2 (SGLT-2) inhibitors. The primary mechanism involved in SGLT2 inhibitors induced eDKA would due to increased lipolysis and ketone body reabsorption. SGLT2i also tend to increase the pancreatic alpha cells, which simultaneously blocks the beta cells, thereby causing an disruption in glucagon/insulin ratio that accounts to enhanced lipolysis and ketogenesis, which is clinically manifested with Fatigueness, stomach pain, nausea and vomiting resulting in reduced blood pressure and dehydration, altered psychological condition, dyspnea, rapid breathing, loss of appetite, pyrexia and tachycardia. Despite lower blood glucose levels or the absence of urine ketones, euglycemic DKA is difficult to diagnose and should be examined in the differential diagnosis of an ill patient who as a previous history of diabetes mellitus. eDKA is often triggered by insulin absence or dose drop, severe acute sickness, dehydration, strenuous activity, surgeries, low-carbohydrate meals, or heavy alcohol or drug abuse. Making the definitive diagnosis using conventional diagnostic tools and clinical standards, as well as coordinating fluid resuscitation, insulin treatment, and electrolyte replacement based on information gained from prompt patient observing and knowledge of resolution criteria, are all components of management and the prevention method includes patient and physician education on risk and precipitating factors and suspending SGLT2 inhibitors therapy may reduce SGLT2 inhibitor-induced eDKA, which are more critical. This review briefly illustrates on the signs &amp; symptoms, mechanism of induction, investigation and diagnosis, prevention and treatment of SGLT2 inhibitors-induced Euglycemic diabetic ketoacidosis (eDKA)

A Re-audit of the Management of Diabetic Ketoacidosis (DKA): The Importance of the Seven-Day Working Inpatient Diabetes Specialist Nurse Service.

Background Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency due to insulin deficiency in patients with diabetes mellitus. The United Kingdom national survey and local audits of the management of DKA have revealed several areas of suboptimal care, and room for improvement, necessitating the need for intensified education, updating local guidelines, and increased recruitment of seven-day working inpatient diabetes specialist nurses. Therefore, this project aimed to re-audit our adherence to the DKA treatment guidelines. Methodology A retrospective re-audit examining patient admissions with DKA between October 2022 and September 2023. A list of 18 standards/criteria, adopted from the Joint British Diabetes Society (JBDS) DKA treatment guidelines was used for this re-audit. Results were compared with that of the previous audit. Results We had 126 patients admitted with DKA between October 2022 and September 2023. There were 62 males and 64 females with an average (range) age of 46.5 (19-92) years. Eighty percent had type 1 diabetes, and common precipitating factors for admission included infection and poor adherence to insulin treatment. The median (IQR) length of hospital stay was 2.1 (1.0-5.1) days. Compared to the previous audit, improvements occurred in 11 of 18 standards/criteria. This included timely commencement of intravenous fluids and fixed-rate insulin, commencing glucose infusion to prevent hypoglycemia,potassium replacement, continuation of long-acting insulin during treatment, timely conversion to variable-rate insulin infusion, and conversion to the usual subcutaneous insulin regimen. Additionally, 124 patients (98.4%) were reviewed at least once by the inpatient diabetes specialist nurses (DSN) during their admission. Complications of treatment, namely, iatrogenic hypoglycemia and transient hypokalemia occurred in 13 (10.3%) and 40 (31.7%) patient admissions, respectively. Conclusions This re-audit demonstrated improved adherence to the guidelines during several steps in the management of DKA. It also demonstrated room for improvement regarding other aspects of care. The importance of continued education, accurate documentation, and the presence of seven-day working inpatient DSN cover cannot be overemphasized.

Evaluation of the Effect of Fluid and Electrolyte Therapy on Electrolytes and Acidosis Resolution Time in Diabetic Ketoacidosis

Objective: Fluid replacement and insulin infusion are the cornerstones of treatment of diabetic ketoacidosis, but the optimal volume, rate of infusion, and electrolyte content of fluid replacement have been controversial. The aim of this study was to investigate the effects of treatment on pH, bicarbonate (HCO3), anion gap, chloride, and potassium levels as well as time to resolution of acidosis in children with diabetic ketoacidosis. Material and Methods: Ninety-six episodes with diabetic ketoacidosis between January 2015-December 2017 were evaluated. Results: The mean resolution time of acidosis was 13.4±7.1 hours. Anion gap was returned to normal in 68 (70.8%) episodes at the 4th hour of treatment with a mean of 11±4.2 mmol/L. Episodes with potassium phosphate (KPO4) replacement resulted in a faster increase in pH and a significantly shorter resolution time of acidosis (p&amp;lt;0.001). Acidosis persisted at the 16th hour of treatment in episodes with lower pH, lower serum bicarbonate (HCO3) and higher white blood cell (WBC) counts on admission (p&amp;lt;0.001, p=0.003 p=0.033, respectively). Hyperchloremia (Cl/Na ratio &amp;gt; 0.79) was observed in 97% of cases after 8 hours of treatment. Conclusion: Although the value of the anion gap in predicting acidosis is controversial, severe DKA episodes and high white blood cell count at admission; potassium replacement with high amounts of chloride and KCl containing fluids given during treatment have been associated with a longer recovery time of acidosis.

Evaluation of the Effects of Incorporating Long-Acting Subcutaneous Insulin Into the Standard Treatment Protocol for Diabetic Ketoacidosis in Children

Background: Despite the progress made in the treatment of type 1 diabetes, the incidence of diabetic ketoacidosis (DKA) in children is still increasing, and its management requires hospitalization in the pediatric intensive care unit (PICU). It is important to find a new and low-risk treatment method to shorten the recovery time from DKA. Objectives: This study aimed to evaluate the effectiveness and safety of integrating two different types of long-acting subcutaneous insulin into the standard treatment for DKA in children. Methods: The study was conducted in the PICU, and comprehensive monitoring was performed throughout the process. Patients aged between 2 and 15 years were divided into three groups: two intervention groups receiving the addition of two types of long-acting insulin, Detemir and Glargine, to the standard treatment, and a control group. Each group consisted of 36 individuals. The impact of the intervention on the recovery time from DKA and the potential complications were investigated in all three groups. Results: The analysis of the results revealed a significant difference in the duration of exiting the acute phase among the groups. Additionally, the post-hoc test demonstrated that the recovery time for ketoacidosis in the Detemir arm was significantly shorter than in the standard arm (P = 0.008). However, it is important to note that there were no significant differences in the occurrence of common complications among the three study groups. Conclusions: Based on the findings, it appears that incorporating specific types of long-acting subcutaneous insulin into the standard treatment of DKA in children leads to a reduction in the resolution time of the acute phase of ketoacidosis. Importantly, this approach does not introduce additional complications. Consequently, it has the potential to optimize resource allocation and enhance patient care by freeing up beds in the PICU.

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

Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip. Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001). In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.