Evaluation of Ward Management of Diabetic Ketoacidosis

Nemecek, Branden D.; Hermayer, Kathie L.; Arnold, Pamela C.; Bohm, Nicole

doi:10.2337/diaclin.32.3.100

Cited by 7 publications

(7 citation statements)

References 19 publications

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“…Currently, we average about 200 IV insulin drips monthly at our institution, including the operating room, recovery room, medical-surgical floors and in the ICUs. 10 Most institutions permit IV insulin drips only in the ICUs as was the practice at our institution until resources were provided to improve hospital diabetes management. Education and support for nursing staff provided an avenue for noncritical adult patients who required an IV insulin drip to be managed on the general medical-surgical units, as well as all the ICUs.…”

Section: Musc Identified the Paper Column-based IV Insulinmentioning

confidence: 99%

Hospital Guidelines for Diabetes Management and the Joint Commission-American Diabetes Association Inpatient Diabetes Certification

Arnold

Scheurer

Dake³

et al. 2016

The American Journal of the Medical Sciences

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Section: Musc Identified the Paper Column-based IV Insulinmentioning

confidence: 99%

Hospital Guidelines for Diabetes Management and the Joint Commission-American Diabetes Association Inpatient Diabetes Certification

Arnold

Scheurer

Dake³

et al. 2016

The American Journal of the Medical Sciences

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“…In the United States of America, 43 % of the total medical costs for diabetes is spent on hospital inpatient care [ 6 ]. The costs of DKA treatment are significant, with estimated mean expenses for a single hospitalization ranging from $7470 to $20,864 [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Predictors and treatment outcome of hyperglycemic emergencies at Jimma University Specialized Hospital, southwest Ethiopia

2015

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BackgroundDiabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) commonly known as hyperglycemic emergencies are the two most common life-threatening acute metabolic complications of diabetes. The objective of this study is to assess predictors and treatment outcome of hyperglycemic emergencies (HEs) among diabetic patients admitted to Jimma University Specialized Hospital (JUSH).MethodsIt is a three year retrospective review of medical records of patients admitted with HEs at JUSH. Patient demographics, admission clinical characteristics, precipitants, insulin used and treatment outcomes were extracted. Statistical analysis was done using student’s t test, Chi square test, and binary logistic regression with level of α set at 0.05. Statistical significance was considered for variables with p < 0.05.ResultsComplete data was available for 163 out of 421 patients admitted with HEs. The majority (62.6 %) were males. Mean age of patients was 36.6 ± 15.9 years. About 64 % of patients had type 1 diabetes. About 93 % of the participants developed DKA. The most common precipitants of HEs were infections 95 (59 %), non-compliance to medications 52 (32.3 %), and newly diagnosed diabetes 38 (23.6 %). Recurrent hyperglycemia, hypoglycemia and ketonuria occurred in 88 (54 %), 34 (20.9 %) and 31 (20.5 %) patients respectively. Mean amount of insulin used and duration of treatment till resolution of DKA were 136.85 ± 152.41 units and 64.38 ± 76.34 h respectively. The median length of hospital stay was 6 days. Mortality from HEs was 16 (9.8 %). Admission serum creatinine >1.2 mg/dL (P = 0.018), co-morbidity (P < 0.001) and sepsis (P = 0.014) were independent predictors of HEs mortality.ConclusionsInfections, non-compliance and new onset diabetes were the most common precipitants of HEs. Length of hospital stay and mortality were high. High use of insulin, recurrent hyperglycemia, hypoglycemia, and ketonuria were common during HEs management. Elevated serum creatinine, sepsis and co-morbidity are independent predictors of HEs mortality.

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“…Our time to anion gap closure of 10.9-11.5hours was similar to the previously mentioned study that saw 10.3-10.4hours. 22 There were multiple limitations to this study. First, the study was single-centered and utilized a small sample size of thirty patients.…”

Section: Discussionmentioning

confidence: 96%

“…19 However, none of the available data has analyzed factors leading to AGRO in patients with diabetic ketoacidosis. One study evaluated the impact of initiating subcutaneous insulin glargine within twelvehours of intravenous insulin infusion and found that this is a safe method for preventing future hyperglycemia without increased risk of hypoglycemia.…”

Section: Discussionmentioning

confidence: 99%

“…21 In contrast, a 2014 study evaluating adult patients illustrated anion gap closure at approximately 10.3hours. 22 However, there are no studies that identify factors and patient characteristics leading to anion gap re-opening, and thus the purpose of this retrospective study. Our study illustrated that factors such as higher anion gap on admission, older age, and higher serum glucose may require more restrictive anion gap goals in order to improve patient outcomes and decrease length of stay.…”

Section: Discussionmentioning

confidence: 99%

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Evaluation of Factors Leading to Anion Gap Re-Opening in Adults with Diabetic Ketoacidosis

Adams¹

2017

PPIJ

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Abbreviations: DKA, diabetic ketoacidosis; AGRO, anion gap re-opening; ADA, american diabetes association; CPOE, computerized physician order entry Introduction BackgroundDiabetic ketoacidosis (DKA) is a rare yet serious hyperglycemic complication of diabetes. In 2009, there were 140,000 hospitalizations for DKA with an average hospital stay of 3.4days. Common precipitating factors include insulin omission, infection, acute cardiovascular event, acute endocrine events, and surgical procedures. The majority of patients experiencing DKA are between the ages of 45 and 65, with two-thirds of patients with a diagnosis of type one diabetes. 1,2DKA occurs as a result of insulin deficiency and increased counter-regulatory hormones. These metabolic alterations lead to lipolysis and hepatic fatty acid oxidation to ketone bodies, leading to ketonemia and metabolic acidosis. DKA is diagnosed based on decreased arterial pH, a serum bicarbonate less than 18mEq/L, presence of urine and serum ketones, and an anion gap >12. American Diabetes Association recommended management of DKA includes treatment with intravenous crystalloid fluids and providing regular insulin while managing electrolyte derangements. Recommended insulin dosing regimens include 0.1unit/kg IV bolus with 0.1unit/kg/ hr IV continuous insulin infusion or 0.14units/kg/hr without a bolus. Unless the episode of DKA is mild, patients should be treated with continuous intravenous insulin until blood glucose <200mg/dl and two of the following criteria are met: serum bicarbonate ≥15mEq/L, venous pH >7.3, or anion gap ≤12mEq/L. At this point, the patient may be transitioned to subcutaneous insulin therapy. 3The anion gap is an approximate measurement of ions, and an elevated anion gap will occur when there is an excess of anions to cations in the blood. In DKA, an elevated anion gap indicates that lactate is continuing to be produced and thus, the body has not yet been able to achieve normal insulin-glucose regulation. Closure of the anion gap is a marker utilized by ADA to indicate that DKA has resolved. 4 Literature evaluating diabetic ketoacidosis is limited and has yet to evaluate factors leading to anion gap re-opening (AGRO). ObjectiveThe purpose of this quality improvement project was to identify factors leading to anion gap-reopening as well as areas of improvement in the glycemic management of patients with diabetic ketoacidosis at a large academic medical center. The primary objective was incidence of AGRO, defined as an anion gap >15. Anion gap >15 was chosen as this was defined as the upper limit of normal within our computerized physician order entry (CPOE) system, despite the American Diabetes Association (ADA) guidelines recommendation to target an anion gap of 10-12. AbstractPurpose: The purpose of this quality improvement project is to identify factors leading to gap re-opening. Methods:This study was a single-centered, retrospective chart review. The population included all adult patients admitted to a large academic medical center from December 201...

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Evaluation of Ward Management of Diabetic Ketoacidosis

Cited by 7 publications

References 19 publications

Hospital Guidelines for Diabetes Management and the Joint Commission-American Diabetes Association Inpatient Diabetes Certification

Hospital Guidelines for Diabetes Management and the Joint Commission-American Diabetes Association Inpatient Diabetes Certification

Predictors and treatment outcome of hyperglycemic emergencies at Jimma University Specialized Hospital, southwest Ethiopia

Evaluation of Factors Leading to Anion Gap Re-Opening in Adults with Diabetic Ketoacidosis

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