Abstract:Introduction Diabetic ketoacidosis is a life-threatening condition that requires prompt management. Objectives We aimed to assess the impact of adherence to potassium replacement protocol according to the guidelines of Diabetes Poland on the duration of diabetic ketoacidosis (DKA) treatment. Patients and methods This retrospective analysis included 242 adults (median age, 27 years; range, 21-38 years). Nonadherence to potassium replacement protocol was assessed, along with the relationship between nonadherence… Show more
“…The extent of non-adherence to the treatment protocol for the management of DKA is also a reason for hypokalemic events 76. Abela et al56 reported that potassium was given to the patients at a later stage of DKA resolution, with the main reasons being lack of clear instructions or secondary to not following the DKA management protocol to analyze the blood for potassium concentration; importantly, the volume of potassium resuscitation was higher and aggressive when initiated.…”
Section: Discussionmentioning
confidence: 99%
“…Although the well established guidelines strongly give recommendations regarding potassium monitoring and supplementation in DKA, none of these guidelines suggest using the pH-adjusted corrected potassium level to initiate potassium resuscitation or adjust the treatment plan 4–7. And on top of it, count to carry out the recommendations for potassium resuscitation remains very low, regardless of time, whether it is observed in the distant9,48,54,56,71 or near past 76. Even further, despite all the included studies in the current review that were either depicting important parameters of DKA or experimenting with its management to improve patient oriented outcomes, not a single study demonstrated the impact of potassium and acidosis on cardiovascular outcomes in DKA patients, which remains an area to explore further.…”
Background
During the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events.
Objective
To assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA.
Methodology
Seven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale.
Results
Forty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level.
Conclusion
The evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.
“…The extent of non-adherence to the treatment protocol for the management of DKA is also a reason for hypokalemic events 76. Abela et al56 reported that potassium was given to the patients at a later stage of DKA resolution, with the main reasons being lack of clear instructions or secondary to not following the DKA management protocol to analyze the blood for potassium concentration; importantly, the volume of potassium resuscitation was higher and aggressive when initiated.…”
Section: Discussionmentioning
confidence: 99%
“…Although the well established guidelines strongly give recommendations regarding potassium monitoring and supplementation in DKA, none of these guidelines suggest using the pH-adjusted corrected potassium level to initiate potassium resuscitation or adjust the treatment plan 4–7. And on top of it, count to carry out the recommendations for potassium resuscitation remains very low, regardless of time, whether it is observed in the distant9,48,54,56,71 or near past 76. Even further, despite all the included studies in the current review that were either depicting important parameters of DKA or experimenting with its management to improve patient oriented outcomes, not a single study demonstrated the impact of potassium and acidosis on cardiovascular outcomes in DKA patients, which remains an area to explore further.…”
Background
During the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events.
Objective
To assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA.
Methodology
Seven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale.
Results
Forty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level.
Conclusion
The evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.
“…To avoid hypokalaemia, we recommend measuring serum potassium 2 h after starting insulin administration and every 4 h thereafter until the resolution of DKA. Use of too low or too high doses of potassium compared with the recommended potassium replacement protocols in the management of DKA has been associated with longer hospital stays [148].…”
Section: Section 4 What Is the Recommended Treatment Of Dka And Hhs?mentioning
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.
“…To avoid hypokalemia, we recommend measuring serum potassium 2 h after starting insulin administration and every 4 h thereafter until the resolution of DKA. Use of too low or too high doses of potassium compared with the recommended potassium replacement protocols in the management of DKA has been associated with longer hospital stays (148).…”
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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