Literature Review: Hyperglycemic Crisis

The Joint British Diabetes Societies (JBDS) and American Diabetes Association (ADA) guidelines provide evidence-based recommendations for managing diabetic ketoacidosis (DKA). The JBDS guidelines were last updated in 2021, while the ADA guidelines were last updated in 2009. Both are internationally recognized resources for treating DKA.

Joint British Diabetes Societies (JBDS)

The JBDS guidelines divide diabetic ketoacidosis (DKA) treatment into timed phases – immediate management (0-60 minutes), 60 minutes to 6 hours, 6-12 hours, and beyond 12 hours.

0-60 Minutes:

• Confirm DKA diagnosis based on hyperglycemia, ketosis, and acidosis.
• Begin 0.9% saline infusion after checking blood pressure – 500-1000 mL boluses if hypotensive, then 1L over 1 hour if normotensive.
• Start intravenous insulin infusion at 0.1 units/kg/hr. Continue long-acting subcutaneous insulin at usual dose.
• Check electrolytes, venous blood gas, kidney function. Start ECG monitoring.
• Identify and treat precipitating causes (infection, medication changes, etc).
• If the individual normally takes long acting basal insulin (e.g. glargine, degludec, detemir, or human isophane insulin) continue this at the usual dose and usual time

60 Minutes to 6 Hours:

• Continue 0.9% saline infusion with potassium replacement as needed.
• Increase insulin by 1-2 units/hr if ketones not falling by 0.5 mmol/L/hr, bicarbonate not rising by 3 mmol/L/hr, or glucose not falling by 3 mmol/L/hr.
• When glucose <14 mmol/L, start 10% dextrose infusion at 125 mL/hr alongside saline.
• Monitor ketones, electrolytes, fluid balance, and mental status hourly.
• Those presenting with newly diagnosed type 1 diabetes should be given long acting basal insulin (e.g. glargine, detemir or degludec – or human NPH insulin, depending on local policy) at a dose of 0.25 units/Kg subcutaneously once daily to mitigate against reboundketosis.  

6-12 Hours:

• Continue 0.9% saline and dextrose infusions.
• Watch for fluid overload symptoms.
• Check for DKA resolution (ketones <0.6 mmol/L, venous pH >7.3).
• If resolved and eating/drinking, transition to subcutaneous insulin.

Beyond 12 Hours:

• DKA should resolve within 24 hours. Seek senior help if not resolved.
• Transition to subcutaneous insulin if ketosis resolved and patient is eating/drinking.
• Continue treating any precipitating factors.

American Diabetes Association (ADA) guidelines

The ADA guidelines classify DKA as mild, moderate, or severe based on mental status, acidosis severity, and ketosis. Initial management is focused on fluid resuscitation, insulin administration, and identification of precipitating causes.

Fluid Therapy

• Initial fluid is 0.9% saline at 15-20 mL/kg over the first 1-2 hours.
• The rate is then reduced to 250-500 mL/hr.
• Patients with normal or high corrected sodium levels can receive 0.45% saline.
• Potassium is replaced as needed to maintain levels in the normal range.
• Once glucose is <200 mg/dL, begin 5% dextrose to facilitate continued insulin administration.

Insulin Therapy

• Begin intravenous insulin infusion at 0.1 units/kg/hr. No insulin bolus is needed.
• Increase insulin infusion by 1-2 units/hr if glucose decrease is <50-75 mg/dL/hr.
• Once glucose reaches 200-300 mg/dL, reduce insulin infusion to 0.02-0.05 units/kg/hr.
• Transition to subcutaneous insulin when patient is able to eat.

Bicarbonate Therapy

• Bicarbonate therapy is not routinely recommended.
• May be used in severe DKA (pH <6.9) until pH is >7.0.

Phosphate Therapy

• Routine phosphate replacement is not recommended.
• May be used for hypophosphatemia symptoms like myocardial dysfunction, respiratory depression, etc.

The ADA guidelines provide a comprehensive overview of DKA treatment focused on fluid resuscitation, insulin infusion titration based on glycemic response, electrolyte monitoring and replacement, and transition to subcutaneous insulin when recovery criteria are met. Key monitoring parameters include glucose, electrolytes, venous blood gases, fluid balance, and mental status.

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Clinical Literature to Review

The objective of this lesson is to critically review and understand two scholarly articles related to the management of diabetic ketoacidosis (DKA). After reading each article, you will complete a short quiz to assess your comprehension and ability to apply the knowledge in a clinical setting.

Articles for Review:

• Article 1:
  • Title: Prospective randomized trial of insulin glargine in acute management of diabetic ketoacidosis in the emergency department: a pilot study
  • Authors: P. Doshi, A.J. Potter, Santos D. De Los, et al.
  • Journal: Acad Emerg Med, 22 (6) (2015 Jun), pp. 657-662
  • Link: Read Article 1
• Article 2:
  • Title: Bicarbonate in diabetic ketoacidosis – a systematic review
  • Authors: Chua HR, Schneider A, Bellomo R
  • Journal: Ann Intensive Care. 2011 Jul 6;1(1):23
  • Link: Read Article 2

Access to Articles:

You may need to utilize your institutional access to PubMed or other academic databases to access the full text of these articles.

 

Steps:

• Review Article 1:
  Click on the link provided for Article 1 and carefully read through the article. Take notes on the methodology, results, and conclusions.
• Review Article 2:
  Click on the link provided for Article 2 and read the article in detail. As with Article 1, jot down key points from the methodology, results, and conclusions.
• Complete the Quiz:
  After thoroughly reviewing both articles, proceed to the quiz section to answer questions based on these articles.

 

Tips:

• Focus on the clinical implications of each study.
• Consider how the findings can be applied in a real-world healthcare setting.