Prevalence of Diabetes Ketoacidosis Rises and Still No Strict Treatment Adherence

Jervis, Alex; Champion, Susannah; Figg, Gemma; Langley, Jane; Adams, Gary G.

doi:10.2174/157339913804143199

Cited by 17 publications

(11 citation statements)

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“…The current mainstay of insulin therapy in DKA is continuous intravenous infusion for its rapid onset and ease of dose titration (1, 2). Some institutions require intravenous insulin infusions to be managed in the intensive care setting and thus some advocate for the use of subcutaneous or intramuscular injections in order to avoid an intensive care admission (1, 46–48). …”

Section: Resultsmentioning

confidence: 99%

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Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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BackgroundDiabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs).ObjectiveTo review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes.MethodsOvid Medline searches were conducted with limits “all adult” and published between “1973 to current” applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers’ assessment of title, abstract, and availability.ResultsA total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over “sliding scale” insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1–2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes.ConclusionThere are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.

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Section: Resultsmentioning

confidence: 99%

“…Limited evidence suggests that the use of a protocol, whether based on national guidelines or individual institution-formed guidelines leads to a better adherence to key treatment principles and improved patient outcome (4, 12, 46, 72–77). …”

Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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“…The prevalence of type 1 diabetes 13 and DKA [13][14][15] are increasing. The Institute of Medicine and the Institute for Healthcare Improvement have released a number of reports highlighting methods to improve the quality and safety of health care.…”

Section: Discussionmentioning

confidence: 99%

Improving Care for Pediatric Diabetic Ketoacidosis

Koves

Leu²,

Spencer³

et al. 2014

Pediatrics

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OBJECTIVE: We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures.METHODS: Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS:Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations. CONCLUSIONS:Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities. Pediatrics 2014;134:e848-e856 Dr Koves drafted, wrote, and submitted the manuscript; developed the design for manuscript and metrics data definitions; interpreted the data; formatted the manuscript; facilitated contributions; developed the figures, tables, references, and reference formatting; and facilitated publication of the final version; she provided oversight for all aspects of the development of the diabetic ketoacidosis (DKA) clinical standard work package; Dr Leu made substantial contributions to the conception and revision of clinical guidelines, architected and updated clinical decision supports used to support the project, reviewed analysis of data, composed a portion of the original manuscript, and edited all of the final manuscript; Ms Spencer performed data analysis and statistical significance testing and contributed writing to the methods of evaluation, results, and analysis sections; Ms Popalisky contributed writing to the methods and discussion sections and assisted with review and revising drafts of the manuscript; Ms Drummond contributed to writing the methods and discussion sections...

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“…Despite their proven effectiveness, a varying degree of non-adherence to guidelines has been documented in the literature compromising the success of published protocols. [16][17][18][19] Successful implementation of the conventional DKA protocol requires not only careful assessment of the clinical status of the patient and laboratory values, but frequent changes to intravenous fluids between saline and dextrose solutions. 2 The 'two-bag system' was first described in the early 1990s in pediatric patients.…”

Section: Introductionmentioning

confidence: 99%

Comparison of a ‘two-bag system’ versus conventional treatment protocol (‘one-bag system’) in the management of diabetic ketoacidosis

Munir

Fargo

Garrison

et al. 2017

BMJ Open Diab Res Care

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ObjectiveWe compared the conventional ‘one-bag protocol’ of management of diabetic ketoacidosis (DKA) with the ‘two-bag protocol’ which utilizes two bags of fluids, one containing saline and supplemental electrolytes and the other containing the same solution with the addition of 10% dextrose.Research design and methodsA retrospective chart review and analysis was done on adult patients admitted for DKA to the Riverside University Health System Medical Center from 2008 to 2015. There were 249 cases of DKA managed by the one-bag system and 134 cases managed by the two-bag system.ResultsThe baseline patient characteristics were similar in both groups. The anion gap closed in 13.56 hours in the one-bag group versus 10.94 hours in the two-bag group (p value <0.0002). None of the individual factors significantly influenced the anion gap closure time; only the two-bag system favored earlier closure of the anion gap. Plasma glucose levels improved to <250 mg/dL earlier with two-bag protocol (9.14 vs 7.82 hours, p=0.0241). The incidence of hypoglycemic events was significantly less frequent with the two-bag protocol compared with the standard one-bag system (1.49% vs 8.43%, p=0.0064). Neither the time to improve serum HCO3 level >18 mg/dL nor the hospital length of stay differed between the two groups.ConclusionsOur study indicates that the two-bag protocol closes the anion gap earlier than the one-bag protocol in adult patients with DKA. Blood glucose levels improved faster with the two-bag protocol compared with the one-bag protocol with fewer associated episodes of hypoglycemia. Prospective studies are needed to evaluate the clinical significance of these findings.

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Prevalence of Diabetes Ketoacidosis Rises and Still No Strict Treatment Adherence

Cited by 17 publications

References 0 publications

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

Improving Care for Pediatric Diabetic Ketoacidosis

Comparison of a ‘two-bag system’ versus conventional treatment protocol (‘one-bag system’) in the management of diabetic ketoacidosis

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