Controversies in the management of hyperglycaemic emergencies in adults with diabetes

Abstract

Hyperglycaemic emergencies are associated with significant morbi-mortality and healthcare costs. Management consists on fluid replacement, insulin therapy, and electrolyte correction. However, some areas of patient management remain debatable. In patients without respiratory failure or haemodynamic instability, arterial and venous pH and bicarbonate measurements are comparable. Fluid choice varies upon replenishment phase and patient's condition. If patient is severely hypovolaemic, normal saline solution should be the first option. However, if patient has mild/moderate dehydration, fluid choice must take in consideration sodium concentration. Insulin therapy should be guided by β-hydroxybutyrate normalization and not by blood glucose. Variations of conventional insulin infusion protocols emerged recently. Priming dose of insulin may not be required, and fixed rate insulin infusion represents the best option to suppress hepatic glucose production, ketogenesis, and lipolysis. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycaemia. Simpler protocols using subcutaneous rapid-acting insulin analogues for mild/moderate diabetic ketoacidosis treatment have proven to be safe and effective, but further studies are required to confirm these results. Treatment with bicarbonate, phosphate, and low-molecular-weight heparin is still disputable, and randomized controlled trials are urgently needed to optimize patient management and decrease the morbi-mortality of hyperglycaemic emergencies.

Diabetic ketoacidosis in adult patients: an audit of factors influencing time to normalisation of metabolic parameters

“…While there may be some indication for its use in severe DKA with pH <6.9, there have been no prospective randomised studies to support this approach. There are also concerns that bicarbonate replacement may be associated with hypokalaemia, central nervous system acidosis and cerebral oedema …”

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

“…However, this rate has not been proven to be sufficient to suppress lipolysis and ketosis 72. Additional studies are needed to assess whether the potential benefits of reduction of the insulin rate (reduced hypoglycemia and hypokalemia) justify the potential delay in resolution of diabetic ketoacidosis.…”

Therapeutic and Evolutionary Characteristics of Diabetic Ketosis Decompensations after a Decade at the University Hospital of Cotonou, Benin

“…On the other hand, some authors have reported higher rates of mortality: 17.14% in South Africa in 2017 [23]; 27.5% in the Democratic Republic of Congo in 2014 [6]; 40.5% in Mali in 2007 [24] and 48.7% in Burkina Faso in 2017 [1]. In the northern countries, the death rates are rather lower: less than 1% in the USA in 2017 and 2016 [25,26]; 1.2% in Spain in 2015 [27]; 1.7% in China in 2016 [28]. In addition, taking into account the publication dates of the various studies, there is a decrease in mortality rates in the most recent studies and certainly because of therapeutic progress and improvements in technical facilities.…”