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Takahashi K, Uenishi N, Sanui M, Uchino S, Yonezawa N, Takei T, Nishioka N, Kobayashi H, Otaka S, Yamamoto K, Yasuda H, Kosaka S, Tokunaga H, Fujiwara N, Kondo T, Ishida T, Komatsu T, Endo K, Moriyama T, Oyasu T, Hayakawa M, Hoshino A, Matsuyama T, Miyamoto Y, Yanagisawa A, Wakabayashi T, Ueda T, Komuro T, Sugimoto T, Sasabuchi Y. High versus low chloride load in adult hyperglycemic emergencies with acute kidney injury: a multicenter retrospective cohort study. Intern Emerg Med 2024; 19:959-970. [PMID: 38488997 DOI: 10.1007/s11739-024-03556-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/04/2024] [Indexed: 03/17/2024]
Abstract
Hyperglycemic emergencies frequently lead to acute kidney injury (AKI) and require treatment with large amount of intravenous fluids. However, the effects of chloride loading on this population have not yet been investigated. We conducted a multicenter, retrospective, cohort study in 21 acute-care hospitals in Japan. The study included hospitalized adult patients with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) who had AKI upon arrival. The patients were classified into high and low chloride groups based on the amount of chloride administered within the first 48 h of their arrival. The primary outcome was recovery from AKI; secondary outcome was major adverse kidney events within 30 days (MAKE30), including mortality and prolonged renal failure. A total of 390 patients with AKI, including 268 (69%) with DKA and 122 (31%) with HHS, were included in the study. Using the criteria of Kidney Disease Improving Global Outcomes, the severity of AKI in the patients was Stage 1 (n = 159, 41%), Stage 2 (n = 121, 31%), and Stage 3 (n = 110, 28%). The analysis showed no significant difference between the two groups in recovery from AKI (adjusted hazard ratio, 0.96; 95% CI 0.72-1.28; P = 0.78) and in MAKE30 (adjusted odds ratio, 0.91; 95% CI 0.45-1.76; P = 0.80). Chloride loading with fluid administration had no significant impact on recovery from AKI in patients with hyperglycemic emergencies.Trial Registration This study was registered in the UMIN clinical trial registration system (UMIN000025393, registered December 23, 2016).
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Affiliation(s)
- Kyosuke Takahashi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture, 330-0834, Japan.
- Department of Anesthesiology and Critical Care Medicine, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan.
| | - Norimichi Uenishi
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture, 330-0834, Japan
| | - Shigehiko Uchino
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture, 330-0834, Japan
| | - Naoki Yonezawa
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Tetsuhiro Takei
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, Japan
- Division of Nephrology, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
| | - Hirotada Kobayashi
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Shunichi Otaka
- Department of Emergency Medicine, International University of Health and Welfare Narita Hospital, Narita, Chiba, Japan
- Department of Emergency Medicine, Kumamoto Red Cross Hospital, Higashi, Kumamoto, Japan
| | - Kotaro Yamamoto
- Department of Emergency Medicine, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
| | - Hideto Yasuda
- Department of Emergency Medicine, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Omiya, Saitama, Japan
| | - Shintaro Kosaka
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
| | - Hidehiko Tokunaga
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
| | - Naoki Fujiwara
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
- Department of Medicine, Taito Municipal Taito Hospital, Taito, Tokyo, Japan
| | - Takashiro Kondo
- Department of Emergency and Critical Care Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi, Japan
| | - Tomoki Ishida
- Nanohana Clinic, Ikuno, Osaka, Japan
- Department of Emergency Medicine, Yodogawa Christian Hospital, Higashi Yodogawa, Osaka, Japan
| | - Takayuki Komatsu
- Department of Sports Medicine, Faculty of Medicine, Juntendo University, Bunkyo, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima, Tokyo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Sakyo, Kyoto, Japan
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Tottori, Japan
| | - Taiki Moriyama
- Department of Emergency Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
- Department of Emergency Medicine, Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Takayoshi Oyasu
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Atsumi Hoshino
- Department of Critical Care Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
- Department of Emergency and Critical Care Medicine, Toyooka Public Hospital, Toyooka, Hyogo, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo, Kyoto, Japan
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo, Kyoto, Japan
| | - Akihiro Yanagisawa
- Department of Anesthesia, Gyoda General Hospital, Gyoda, Saitama, Japan
- Department of Anesthesiology and Intensive Care, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Tadamasa Wakabayashi
- Department of Medicine, Suwa Central Hospital, Chino, Nagano, Japan
- Department of Cardiology, Suwa Central Hospital, Chino, Nagano, Japan
| | - Takeshi Ueda
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Nakagyo, Kyoto, Japan
| | - Tetsuya Komuro
- Department of Medicine, TMG Muneoka Central Hospital, Shiki, Saitama, Japan
- Department of Critical Care, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Toshiro Sugimoto
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan
- Department of Medicine, National Hospital Organization Higashiohmi General Medical Center, Higashiohmi, Shiga, Japan
| | - Yusuke Sasabuchi
- Department of Real-World Evidence, Graduate School of Medicine, The University of Tokyo, Bunkyo City, Tokyo, Japan
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Fry K, Ryman K, Abdelmonem A, Wang X, Vassaur J, Kataria V. Success of Insulin Infusion Transitions in Moderate to Severe Diabetic Ketoacidosis With Transition Anion Gap of Less Than or Equal to 12 mEq/L Versus Greater Than 12 mEq/L. Hosp Pharm 2024; 59:334-340. [PMID: 38764987 PMCID: PMC11097940 DOI: 10.1177/00185787231218935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
Background: Patients with diabetic ketoacidosis (DKA) are transitioned from intravenous (IV) to subcutaneous (SQ) insulin upon DKA resolution. Although an anion gap (AG) ≤12 mEq/L is recommended before transition to SQ insulin, there are limited data to support this threshold. Objective: To compare the rates of successful transitions to SQ insulin in patients with DKA with an AG ≤ 12 mEq/L versus > 12 mEq/L. Methods: Retrospective cohort study of adult critically ill patients with moderate to severe DKA between September 2019 and December 2022. The primary outcome was the success of insulin transition between patients transitioned with an AG ≤ 12 mEq/L and those transitioned with an AG > 12 mEq/L. Transition was considered successful if the AG did not increase above the value at transition at 24 hours and insulin infusion was not restarted. Secondary outcomes include the individual components of the primary outcome and ICU length of stay (LOS); safety outcomes included hypoglycemia and electrolyte derangements. Results: In total, 92 patients were included, with 43 patients transitioned at AG ≤ 12 mEq/L and 49 patients transitioned at AG > 12 mEq/L. Transition was unsuccessful in 3 patients (7%) with AG ≤ 12 mEq/L and 2 patients (4%) with AG > 12 mEq/L (P = .66). There was no difference in the incidence of the individual components of this outcome between groups or in safety outcomes. Conclusion: This retrospective study showed no difference in success of insulin transition between the groups. Larger studies are needed to evaluate the impact of treatment characteristics on transition success and patient outcomes.
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Affiliation(s)
- Kjersti Fry
- Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Xuan Wang
- Baylor Research Institute, Dallas, TX, USA
| | - John Vassaur
- Baylor University Medical Center, Dallas, TX, USA
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Liu Y, Zhang J, Xu X, Zou X. Comparison of balanced crystalloids versus normal saline in patients with diabetic ketoacidosis: a meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2024; 15:1367916. [PMID: 38836222 PMCID: PMC11148269 DOI: 10.3389/fendo.2024.1367916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/03/2024] [Indexed: 06/06/2024] Open
Abstract
Purpose The optimal resuscitative fluid for patients with diabetic ketoacidosis (DKA) remains controversial. Therefore, our objective was to assess the effect of balanced crystalloids in contrast to normal saline on clinical outcomes among patients with DKA. Methods We searched electronic databases for randomized controlled trials comparing balanced crystalloids versus normal saline in patients with DKA, the search period was from inception through October 20th, 2023. The outcomes were the time to resolution of DKA, major adverse kidney events, post-resuscitation chloride, and incidence of hypokalemia. Results Our meta-analysis encompassed 11 trials, incorporating a total of 753 patients with DKA. There was no significant difference between balanced crystalloids and normal saline group for the time to resolution of DKA (MD -1.49, 95%CI -4.29 to 1.31, P=0.30, I2 = 65%), major adverse kidney events (RR 0.88, 95%CI 0.58 to 1.34, P=0.56, I2 = 0%), and incidence of hypokalemia (RR 0.80, 95%CI 0.43 to 1.46, P=0.46, I2 = 56%). However, there was a significant reduction in the post-resuscitation chloride (MD -3.16, 95%CI -5.82 to -0.49, P=0.02, I2 = 73%) among patients received balanced crystalloids. Conclusion Among patients with DKA, the use of balanced crystalloids as compared to normal saline has no effect on the time to resolution of DKA, major adverse kidney events, and incidence of hypokalemia. However, the use of balanced crystalloids could reduce the post-resuscitation chloride. Systematic review registration https://osf.io, identifier c8f3d.
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Affiliation(s)
- Yuting Liu
- Oncology and Chemotherapy Department, Lishui People’s Hospital, Lishui, China
| | - Jianfeng Zhang
- Department of Orthopedics, Yunhe People’s Hospital, Lishui, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Xiaoyun Zou
- Department of General Practice, Lishui Central Hospital, Lishui, China
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Morace C, Lorello G, Bellone F, Quartarone C, Ruggeri D, Giandalia A, Mandraffino G, Minutoli L, Squadrito G, Russo GT, Marini HR. Ketoacidosis and SGLT2 Inhibitors: A Narrative Review. Metabolites 2024; 14:264. [PMID: 38786741 PMCID: PMC11122992 DOI: 10.3390/metabo14050264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
An acute metabolic complication of diabetes mellitus, especially type 1, is diabetic ketoacidosis (DKA), which is due to an increase in blood ketone concentrations. Sodium/glucose co-transporter-2 inhibitor (SGLT2-i) drugs have been associated with the occurrence of a particular type of DKA defined as euglycemic (euDKA), characterized by glycemic levels below 300 mg/dL. A fair number of euDKA cases in SGLT2-i-treated patients have been described, especially in the last few years when there has been a significant increased use of these drugs. This form of euDKA is particularly insidious because of its latent onset, associated with unspecific symptomatology, until it evolves (progressing) to severe systemic forms. In addition, its atypical presentation can delay diagnosis and treatment. However, the risk of euDKA associated with SGLT2-i drugs remains relatively low, but it is essential to promptly diagnose and manage it to prevent its serious life-threatening complications. In this narrative review, we intended to gather current research evidence on SGLT2i-associated euDKA from randomized controlled trials and real-world evidence studies, its diagnostic criteria and precipitating factors.
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Affiliation(s)
- Carmela Morace
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Giuseppe Lorello
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Federica Bellone
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Cristina Quartarone
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Domenica Ruggeri
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Annalisa Giandalia
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
- Department of Human Pathology of Adulthood and Childhood “G. Barresi”, University of Messina, 98125 Messina, Italy
| | - Giuseppe Mandraffino
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Letteria Minutoli
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Giuseppina T. Russo
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Herbert Ryan Marini
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
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Johnson J, Drincic A, Buddenhagen E, Nein K, Samson K, Langenhan T. Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis. J Diabetes Sci Technol 2024; 18:549-555. [PMID: 38454546 PMCID: PMC11089871 DOI: 10.1177/19322968241235941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. METHODS We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip. RESULTS Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001). CONCLUSIONS In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.
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Affiliation(s)
- Jake Johnson
- Division of Diabetes, Endocrine, and
Metabolism, Department of Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
| | - Andjela Drincic
- Division of Diabetes, Endocrine, and
Metabolism, Department of Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
| | - Emma Buddenhagen
- College of Medicine, University of
Nebraska Medical Center, Omaha, NE, USA
| | - Kaitlyn Nein
- College of Medicine, University of
Nebraska Medical Center, Omaha, NE, USA
| | - Kaeli Samson
- Department of Biostatistics, University
of Nebraska Medical Center, Omaha, NE, USA
| | - Trek Langenhan
- Division of Hospital Medicine,
Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE,
USA
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Yan JW, Slim A, Van Aarsen K, Choi YH, Byrne C, Poonai N, Collins H, Clemens KK. Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a pilot randomised controlled trial. Emerg Med J 2024; 41:103-111. [PMID: 38050056 PMCID: PMC10850620 DOI: 10.1136/emermed-2023-213290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 11/21/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Current diabetic ketoacidosis (DKA) treatment guidelines recommend using normal saline (NS); however, NS may delay DKA resolution by causing more hyperchloremic metabolic acidosis compared with balanced crystalloids. This study's objective was to determine the feasibility of a future multicentred randomised controlled trial (RCT) comparing intravenous Ringer's lactate (RL) with NS in managing ED patients with DKA. METHODS We conducted a parallel-arm, triple-blind, pilot RCT of adults (≥18 years) with DKA at a Canadian academic tertiary care ED. The primary feasibility outcome was recruitment rate (target ≥41.3% of eligible participants over the 1-year study period); the primary efficacy outcome was time elapsed from ED presentation to DKA resolution. The superiority margin for a clinically significant difference was chosen to be a 40% time reduction to DKA resolution. We also assessed the need to break allocation concealment and loss to follow-up. Patients with clinical suspicion for DKA were screened for inclusion and enrolled patients were randomised 1:1 to receive RL or NS. Patients, clinicians and outcome assessors were blinded to allocation. RESULTS We enrolled 52 (25 RL, 27 NS) of 60 eligible patients (86.7%), exceeding our target recruitment rate. There were more patients in the NS group with type 1 diabetes, and more patients in the RL group had an admission co-diagnosis in addition to DKA. For the 44 participants with confirmed laboratory evidence of resolution, median (IQR) time to DKA resolution for RL versus NS was 15.7 (10.4-18.8) and 12.7 (7.9-19.2) hours, respectively. There were no cases where blinding was broken, and there was no loss to follow-up. CONCLUSIONS This pilot trial demonstrated our protocol's feasibility by exceeding our target recruitment rate. Our results may be used to inform future multicentre trials to compare the safety and efficacy of RL and NS in managing DKA in the ED. TRIAL REGISTRATION NUMBER NCT04926740.
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Affiliation(s)
- Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Ahmed Slim
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Kristine Van Aarsen
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Yun-Hee Choi
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Christopher Byrne
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Naveen Poonai
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Departments of Paediatrics, Internal Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Kristin K Clemens
- Lawson Health Research Institute, London, Ontario, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Gilchrist HE, Hatton CJ, Roginski MA, Esteves AM. Impact on Diabetic Ketoacidosis Resolution After Implementation of a 2-Bag Fluid Order Set. Ann Pharmacother 2023; 57:1361-1366. [PMID: 37021360 DOI: 10.1177/10600280231163838] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a serious acute complication of both type 1 and type 2 diabetes that requires prompt management. Limited data exist supporting the use of a 2-bag DKA protocol in adult patients across all levels of care. OBJECTIVE To evaluate the efficacy and safety of a 2-bag DKA protocol in comparison with a traditional DKA management strategy. METHODS Retrospective review of patients admitted with DKA between January 1, 2021, and February 28, 2022, at a single center. Patients were separated into 2 cohorts, traditional or 2-bag. The primary outcome was time to anion gap closure and/or beta-hydroxybutyrate normalization. Secondary outcomes include length of hospitalization, insulin infusion time, and hypoglycemic events. RESULTS One hundred forty-three patients had a DKA order set initiated during their admission, 59 in the traditional cohort and 84 in the 2-bag cohort. Mean time to anion gap closure was shorter in the 2-bag cohort (12.7 vs 16.9 hours; P = 0.005) and beta-hydroxybutyrate normalization (15.6 vs 25.6 hours; P = 0.026). No difference in hospital length of stay (4 vs 6 days; P = 0.113), duration of insulin infusion (41.6 vs 40.6 hours; P = 0.455), or rates of hypoglycemia (6 vs 4; P = 0.872) was seen. CONCLUSION AND RELEVANCE Implementation of a 2-bag DKA protocol in the inpatient setting was associated with a shorter time to anion gap closure and beta-hydroxybutyrate normalization. These findings support the option of expansion of a 2-bag DKA protocol to adult patients across all levels of care irrespective of the admission diagnosis.
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Affiliation(s)
- Hannah E Gilchrist
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Colman J Hatton
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Matthew A Roginski
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Alyson M Esteves
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Wang D, Zhou D, Liu X, Xu Z, Bai T, Hou X. Different dosages of vonoprazan for gastroesophageal reflux disease: study protocol for a pragmatic, crossover-cluster, randomized controlled trial with patient preference arms. Trials 2023; 24:778. [PMID: 38041136 PMCID: PMC10691065 DOI: 10.1186/s13063-023-07760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/27/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Vonoprazan results in more potent acid suppression for gastroesophageal reflux disease (GERD) than proton pump inhibitors. It has only been approved for treating erosive esophagitis in China, but 30-40% of GERD patients cannot achieve the goal of treatment with vonoprazan 20 mg daily. This study aims to investigate whether vonoprazan could relieve the symptoms of Chinese patients with non-erosive reflux disease (NERD) and whether increased dosage or different times of dosing could increase the response rate of GERD. METHODS This study is a pragmatic, open-label, crossover-cluster, randomized controlled trial with patient preference arms. Two thousand eight hundred eighty patients with GERD from 48 hospitals in China will be enrolled. These hospitals will be divided into a compulsory randomization cluster (24 hospitals) and a patient preference cluster (24 hospitals). Patients in the compulsory randomization cluster will be randomized to three regimens according to the crossover-cluster randomization. Patients in the patient preference cluster may choose to receive any regimen if they have a preference; otherwise, patients will be randomly assigned. The three treatment regimens will last 4 weeks, including (1) vonoprazan 20 mg p.o. after breakfast, (2) vonoprazan 20 mg p.o. after dinner, and (3) vonoprazan 20 mg p.o. after breakfast and after dinner. Patients will attend a baseline visit, a 4-week e-diary, a fourth-week visit, and a sixth-month visit online. The primary outcome is the symptom relief rate of all patients after 4-week therapy. Secondary outcomes include the healing rate of EE patients, the severity of symptoms, compliance with the therapy at the fourth-week follow-up visit, recurrent symptoms, and the frequency of self-conscious doctor visits at the sixth-month follow-up visit. DISCUSSION This trial will explore the effectiveness of different regimens of vonoprazan that will be implemented with GERD patients in China. The randomization with patient preferences considered and the crossover-cluster component may improve the robustness and extrapolation of study conclusions. TRIAL REGISTRATION https://www.chictr.org.cn ChiCTR2300069857. Registered on 28 March 2023. PROTOCOL VERSION February 18, 2023, Version 2.
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Affiliation(s)
- Dongke Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dan Zhou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinghuang Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiyue Xu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Bai
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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9
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Barski L, Golbets E, Jotkowitz A, Schwarzfuchs D. Management of diabetic ketoacidosis. Eur J Intern Med 2023; 117:38-44. [PMID: 37419787 DOI: 10.1016/j.ejim.2023.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/09/2023]
Abstract
Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness. There are still controversies regarding certain aspects of DKA management. Different society guidelines have inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA and provide our perspective on these issues. Moreover, we believe that special patient factors and comorbidities should receive more careful attention and consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach and require tailored management strategies. However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, we aim to address unique circumstances and provide an approach to managing complex patients with specific conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate on aspects of latest research with a perspective towards future developments and modifications.
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Affiliation(s)
- Leonid Barski
- Department of Internal Medicine F, Soroka Univerity Medical Center, P.O.Box 151, Beer-Sheva 84101, Israel.
| | - Evgeny Golbets
- Department of Internal Medicine F, Soroka Univerity Medical Center, P.O.Box 151, Beer-Sheva 84101, Israel
| | - Alan Jotkowitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Dan Schwarzfuchs
- Department of Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
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10
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Abstract
This article reviews the most current literature on diabetic ketoacidosis, including how to make the diagnosis and management. It discusses euglycemic diabetic ketoacidosis and the risk factors for this rare but dangerous disease process. Pertinent pearls and pitfalls encountered by the emergency physician when managing these patients are included. Because these patients often stay in the emergency department for prolonged periods, recommendations on transitioning to subcutaneous insulin are included, along with dosing recommendations. Finally, the article reviews how to disposition patients with diabetic ketoacidosis and examines important factors that lead to a successful discharge home.
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Affiliation(s)
- Bobbi-Jo Lowie
- Department of Emergency Medicine, University of Maryland Medical Center, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA
| | - Michael C Bond
- Department of Emergency Medicine, University of Maryland School of Medicine; University of Maryland Medical Center, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA.
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11
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Stultz BR, Ewy MW, Chalmers SJ. 53-Year-Old Man With Dyspnea. Mayo Clin Proc 2023; 98:1697-1701. [PMID: 37923526 DOI: 10.1016/j.mayocp.2023.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Benjamin R Stultz
- Residents in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN, USA
| | - Matthew W Ewy
- Residents in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN, USA
| | - Sarah J Chalmers
- Advisor to residents and Consultant in Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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12
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Attokaran AG, Ramanan M, Hunt L, Chandra K, Sandha R, Watts S, Venkatesh B. Sodium chloride or plasmalyte-148 for patients presenting to emergency departments with diabetic ketoacidosis: A nested cohort study within a multicentre, cluster, crossover, randomised, controlled trial. Emerg Med Australas 2023; 35:657-663. [PMID: 36970972 DOI: 10.1111/1742-6723.14198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE To test the hypothesis that fluid resuscitation in the ED with plasmalyte-148 (PL) compared with 0.9% sodium chloride (SC) would result in a lower proportion of patients with diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission. METHODS We performed a prespecified nested cohort study at two hospitals within a cluster, crossover, open label, randomised, controlled trial comparing the effects of PL versus SC as fluid therapy for patients who presented to the ED with DKA. All patients presenting within a fixed recruitment period were included. The primary outcome was the proportion of patients admitted to ICU. RESULTS Eighty-four patients were enrolled (SC n = 38, PL n = 46). The SC group had a lower median pH on admission (SC: 7.09 [interquartile range (IQR) 7.01-7.21], PL: 7.17 [IQR 6.99-7.26]). The median volume of intravenous fluids administered in ED was 2150 mL (IQR 2000-3200 mL; SC) and 2200 mL (IQR 2000-3450; PL); respectively. A higher proportion of patients in the SC group, 19 (50%), was admitted to ICU compared with PL group, 18 (39.1%); however, after adjustment for pH at presentation and diabetes type in a multivariable logistic regression model, the PL group did not have a significantly different rate of ICU admission compared with the SC group (odds ratio for ICU admission 0.73, 95% confidence interval 0.13-3.97, P = 0.71). CONCLUSION Patients with DKA treated with PL compared with SC in the EDs had similar rates of requiring ICU admission.
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Affiliation(s)
- Antony George Attokaran
- Rockhampton Hospital, Rockhampton, Queensland, Australia
- Rural Clinical School, The University of Queensland, Rockhampton, Queensland, Australia
| | - Mahesh Ramanan
- Caboolture Hospital, Caboolture, Queensland, Australia
- The Prince Charles Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Hunt
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kavita Chandra
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Rajbir Sandha
- Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Stacey Watts
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Wesley Hospital, Brisbane, Queensland, Australia
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13
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Yan JW, Slim A, Van Aarsen K, Choi YH, Byrne C, Poonai N, Collins H, Clemens KK. Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a protocol for a pilot randomized controlled trial. Pilot Feasibility Stud 2023; 9:121. [PMID: 37443083 DOI: 10.1186/s40814-023-01356-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Current guidelines for diabetic ketoacidosis (DKA) recommend treatment with normal saline (NS). However, NS, with its high chloride concentrations, may worsen acidosis and contribute to a hyperchloremic metabolic acidosis. Alternatives to NS are balanced crystalloids (e.g. Ringer's Lactate [RL]) which have chloride concentrations similar to human plasma; therefore, treatment with balanced crystalloids may lead to faster DKA resolution. A recent systematic review and meta-analysis by Catahay et al. (2022) demonstrated the need for more blinded, high-quality trials comparing NS versus RL in the treatment of DKA. METHODS We describe a protocol for BRISK-ED (Balanced crystalloids [RInger's lactate] versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department). Our study is a single-centre, triple-blind, pilot randomized controlled trial (RCT) of adults (≥ 18 years) with DKA presenting to an academic tertiary care ED in London, Canada. Patients with clinical suspicion for DKA will be screened and those found to not meet DKA criteria or have euglycemic DKA will be excluded. We will aim to recruit 52 patients with DKA and will randomize them 1:1 to receive intravenous RL or NS. The primary feasibility outcome will be recruitment rate, and the primary efficacy outcome will be time elapsed from ED presentation to DKA resolution. Secondary outcomes include time to insulin infusion discontinuation, intensive care unit admission, in-hospital death, and major adverse kidney events within 30 days, defined as a composite of: i) death, ii) new renal replacement therapy, or iii) final serum creatinine ≥ 200% baseline at the earliest of hospital discharge or 30 days after ED presentation. Patients, clinicians, and outcome assessors will be blinded to allocation group. We will follow an intention-to-treat analysis. Gehan-Wilcoxon, Mann-Whitney U, or chi-square tests will be used to compare groups as appropriate. DISCUSSION The results of this pilot study will inform the design and feasibility of a full-scale, multicentre RCT to assess fluid choice in adult ED patients with DKA. If proven to demonstrate faster resolution of DKA, administration of balanced crystalloids may replace NS in diabetes treatment guidelines and improve patient and health systems outcomes. TRIAL REGISTRATION ClinicalTrials.gov, Registration # NCT04926740; Registered June 15, 2021.
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Affiliation(s)
- Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada.
| | - Ahmed Slim
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Department of Emergency Medicine, London Health Sciences Centre, London, ON, Canada
| | - Kristine Van Aarsen
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Department of Emergency Medicine, London Health Sciences Centre, London, ON, Canada
| | - Yun-Hee Choi
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Christopher Byrne
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Naveen Poonai
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Departments of Paediatrics, Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Kristin K Clemens
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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14
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Patlolla SR, Devara J, Ameer MA, Patlolla PR, Ponnala M. Euglycemic Diabetic Ketoacidosis in a Patient With Urinary Tract Infection. Cureus 2023; 15:e42594. [PMID: 37641775 PMCID: PMC10460495 DOI: 10.7759/cureus.42594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/31/2023] Open
Abstract
Diabetes Mellitus (DM) is a complex metabolic disease primarily associated with elevated blood glucose levels in the body. Diabetic ketoacidosis (DKA) is the most feared acute presentation of diabetes mellitus (DM) in both type 1 and type 2 diabetes mellitus. Furthermore, euglycemic diabetic ketoacidosis (EDKA) is a relatively rare complication of DM in which the blood glucose levels are usually less than 250 mg/dl with an elevated anion gap metabolic acidosis. It can be a diagnostic challenge due to normal blood glucose levels and often can be overlooked. Physicians should be aware of EDKA; prompt diagnosis and treatment are critical in the timely management of the condition to prevent complications. We present a case of EDKA in a 74-year-old female precipitated by a urinary tract infection which was identified and treated promptly with insulin and dextrose infusion. In addition to that, an important difference between British and American guidelines has been highlighted.
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15
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Tamzil R, Yaacob N, Noor NM, Baharuddin KA. Comparing the clinical effects of balanced electrolyte solutions versus normal saline in managing diabetic ketoacidosis: A systematic review and meta-analyses. Turk J Emerg Med 2023; 23:131-138. [PMID: 37529790 PMCID: PMC10389098 DOI: 10.4103/tjem.tjem_355_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 08/03/2023] Open
Abstract
The first-line treatment of diabetes ketoacidosis (DKA) involves fluid resuscitation with normal saline infusion to correct hypovolemia. Hyperchloremic metabolic acidosis from aggressive normal saline administration was associated with worse clinical outcomes in managing DKA. Other choices for normal saline include balanced electrolyte solutions (BESs). This study aimed to compare the clinical effects between BESs and normal saline in managing DKA. This study was a systematic review of probing articles published from inception to October 2021 in Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Google Scholar, and Scopus. Eight randomized controlled trials with a total of 595 individuals were included. The data were analyzed at 95% confidence level using random-effects models. For the primary outcomes, there was no difference in the duration of DKA resolution. (Mean difference [MD] -4.73, 95% confidence interval [CI] -2.72-4.92; I2 = 92%; P = 0.180). However, there was a significantly lower postresuscitation chloride concentration in the BES (MD 2.96 95% CI - 4.86 to - 1.06; I2 = 59%; P = 0.002). For the secondary outcomes, there was a significant reduction in duration for normalization of bicarbonate in the BES group (MD 3.11 95% CI - 3.98-2.23; I2 = 5%; P = 0.0004). There were no significant differences between groups in duration for recovery of pH, intensive unit admission, and adverse events (mortality and acute renal failure). Resuscitation with BES was associated with decreased chloride and increased bicarbonate values in DKA patients. It suggests that BES prevents DKA patients from hyperchloremic metabolic acidosis.
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Affiliation(s)
- Rozinadya Tamzil
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Normalinda Yaacob
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Norhayati Mohd Noor
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Kamarul Aryffin Baharuddin
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
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16
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Othman MI, Nashwan AJ, Alfayoumi M, Khatib M, Abujaber AA. Plasma-Lyte-148 Versus Normal Saline 0.9% in Diabetic Ketoacidosis Management: A Review. Cureus 2023; 15:e41079. [PMID: 37519584 PMCID: PMC10375921 DOI: 10.7759/cureus.41079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is a critical complication of diabetes mellitus characterized by hyperglycemia, ketonemia, circulatory collapse, hypokalemia, and metabolic acidosis. The therapeutic management of DKA includes vigilant fluid resuscitation to address dehydration and electrolyte imbalances and restore hemodynamic stability. The choice of fluid, either isotonic saline or a balanced electrolyte solution like Plasma-Lyte 148 (PL), is pivotal in the clinical outcomes of DKA patients. Recent studies have compared the effectiveness of these fluid solutions in DKA management, focusing on different clinical outcomes such as the resolution of metabolic acidosis, electrolyte imbalances, the incidence of acute kidney injury, and length of hospital stay. This review examines the literature comparing isotonic saline and balanced electrolyte solutions for fluid resuscitation in DKA, analyzing the associated clinical outcomes. Through synthesizing research findings, this review aims to elucidate the efficacy and potential advantages of utilizing PL as an alternative to traditional isotonic saline for fluid resuscitation in treating DKA. This would further facilitate evidence-based decision-making among healthcare professionals and contribute to optimizing DKA management strategies. Understanding the intricacies and implications of fluid resuscitation is crucial, given its profound impact on patient outcomes in DKA management.
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17
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Gripp KE, Trottier ED, Thakore S, Sniderman J, Lawrence S. Les recommandations en vigueur pour la prise en charge de l'acidocétose diabétique pédiatrique. Paediatr Child Health 2023; 28:128-138. [PMID: 37151921 PMCID: PMC10156930 DOI: 10.1093/pch/pxac120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 06/20/2022] [Indexed: 05/09/2023] Open
Abstract
Pour traiter l'acidocétose diabétique pédiatrique, il faut porter une attention particulière aux liquides et aux électrolytes pour limiter le risque de complications, telles qu'une lésion cérébrale, associée à une morbidité et une mortalité élevées. L'incidence d'œdème cérébral en cas d'acidocétose diabétique n'a pas diminué malgré les protocoles visant la limitation des liquides qui s'appuient sur la restriction de la réanimation liquidienne initiale. Selon de nouvelles données probantes, l'administration précoce de liquides isotoniques n'entraîne pas de risque supplémentaire et peut améliorer les résultats cliniques chez certains patients. Les protocoles et les directives cliniques sont adaptés et axés particulièrement sur la surveillance et le remplacement initiaux et continus des liquides et des électrolytes. Il est maintenant recommandé de commencer par une réanimation à l'aide de liquides isotoniques chez tous les patients dans les 20 à 30 minutes suivant leur arrivée à l'hôpital, suivie par la réplétion du déficit volumique sur une période de 36 heures, en association avec une perfusion d'insuline et des suppléments d'électrolytes, ainsi qu'avec la surveillance et la prise en charge attentives d'une éventuelle lésion cérébrale.
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Affiliation(s)
- Karen E Gripp
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Evelyne D Trottier
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Sidd Thakore
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Jonathan Sniderman
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Sarah Lawrence
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
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18
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Gripp KE, Trottier ED, Thakore S, Sniderman J, Lawrence S. Current recommendations for management of paediatric diabetic ketoacidosis. Paediatr Child Health 2023; 28:128-138. [PMID: 37151932 PMCID: PMC10156932 DOI: 10.1093/pch/pxac119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 06/20/2022] [Indexed: 05/09/2023] Open
Abstract
Treatment of paediatric diabetic ketoacidosis (DKA) includes careful attention to fluids and electrolytes to minimize the risk of complications such as cerebral injury (CI), which is associated with high morbidity and mortality. The incidence of cerebral edema in paediatric DKA has not decreased despite the use of fluid-limiting protocols based on restricting early fluid resuscitation. New evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes in some patients. Protocols and clinical practice guidelines are being adjusted, with a particular focus on recommendations for initial and ongoing fluids and electrolyte monitoring and replacement. Initial isotonic fluid resuscitation is now recommended for all patients in the first 20 to 30 minutes after presentation, followed by repletion of volume deficit over 36 hours in association with an insulin infusion, electrolyte supplementation, and careful monitoring for and management of potential CI.
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Affiliation(s)
- Karen E Gripp
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Evelyne D Trottier
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Sidd Thakore
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Jonathan Sniderman
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Sarah Lawrence
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
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19
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Panchal V, Sivasubramanian BP, Samala Venkata V. Crystalloid Solutions in Hospital: A Review of Existing Literature. Cureus 2023; 15:e39411. [PMID: 37362468 PMCID: PMC10287545 DOI: 10.7759/cureus.39411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.
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Affiliation(s)
- Viraj Panchal
- Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Barath Prashanth Sivasubramanian
- Infectious Diseases, University of Texas Health Science Center at San Antonio, San Antonio, USA
- Internal Medicine, ESIC Medical College & PGIMSR, Chennai, IND
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20
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Zardoost P, Khan Z, Wehrum HL, Martin R. Hypernatremia in Diabetic Ketoacidosis: A Rare Metabolic Derangement Requiring a Cautionary Approach in Fluid Resuscitation. Cureus 2023; 15:e36689. [PMID: 37113360 PMCID: PMC10127550 DOI: 10.7759/cureus.36689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 03/28/2023] Open
Abstract
Diabetic ketoacidosis (DKA) with hypernatremia is an atypical metabolic derangement that warrants additional consideration in choosing IV fluids. Our patient, a middle-aged male with a history of insulin-dependent diabetes mellitus type 2 and hypertension, presented with DKA and hypernatremia in the setting of poor intake, community-acquired pneumonia (CAP), and COVID-19. DKA and hypernatremia led to a meticulous approach to fluid resuscitation, where a crystalloid solution was the choice in treating and preventing exacerbation of either condition. Successful treatment of these conditions requires understanding the unique pathophysiology, which demands further research on management.
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21
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Management of Diabetic Ketoacidosis in Pregnancy. Clin Obstet Gynecol 2023; 66:186-195. [PMID: 36657054 DOI: 10.1097/grf.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Diabetic ketoacidosis (DKA) is a rare, but potentially life-threatening complication of diabetes. Certain physiological changes during pregnancy predispose pregnant individuals to developing DKA. Early recognition and aggressive treatment are essential to avoid maternal and fetal morbidity and mortality. Although laboratory values can help to support, pregnant patients with DKA may not meet the usual criteria and the diagnosis can be made clinically. The key components to treatment include volume replacement, insulin infusion, correction of serum potassium, and fetal monitoring. With appropriate treatment, maternal mortality is low. After recovery, steps should be taken to avoid recurrence.
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22
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Dhatariya KK, Umpierrez G. Gaps in our knowledge of managing inpatient dysglycaemia and diabetes in non-critically ill adults: A call for further research. Diabet Med 2023; 40:e14980. [PMID: 36256494 PMCID: PMC10100017 DOI: 10.1111/dme.14980] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 11/28/2022]
Abstract
AIMS To describe the gaps in knowledge for the care of people in the hospital who have dysglycaemia or diabetes. METHODS A review of the current literature and the authors' knowledge of the subject. RESULTS Recent data has suggested that the prevalence of hospitalised people with diabetes is approximately three times the prevalence in the general population and is growing annually. A wealth of observational data over the last 4 decades has shown that people with hyperglycaemia, severe hypoglycaemia or diabetes, all experience more harm whilst in the hospital than those who do not have the condition. This often equates to a longer length of stay and thus higher costs. To date, the proportion of federal funding aimed at addressing the harms that people with dysglycaemia experience in hospitals has been very small compared to outpatient studies. National organisations, such as the Joint British Diabetes Societies for Inpatient Care, the American Diabetes Association and the Endocrine Society have produced guidelines or consensus statements on the management of various aspects of inpatient care. However, whilst a lot of these have been based on evidence, much remains based on expert opinion and thus low-quality evidence. CONCLUSIONS This review highlights that inpatient diabetes is an underfunded and under-researched area.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, UK
- Norwich Medicine School, University of East Anglia, Norfolk, UK
| | - Guillermo Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia, USA
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23
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Normal saline versus balanced crystalloids in patients with prerenal acute kidney injury and pre-existing chronic kidney disease. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:98-105. [PMID: 36801001 DOI: 10.2478/rjim-2023-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Indexed: 02/20/2023]
Abstract
Introduction Normal saline (N/S) and Ringer's-Lactate (L/R), are administered in everyday clinical practice. Despite that, N/S increases the risk of sodium overload and hyperchloremic metabolic acidosis. In contrast, L/R has lower sodium content, significantly less chloride and contains lactates. In this study we compare the efficacy of L/R versus N/S administration in patients with prerenal acute kidney injury (AKI) and pre-established chronic kidney disease (CKD). Methods In this prospective open-label study we included patients with prerenal AKI and previously known CKD stage III-V without need for dialysis. Patients with other forms of AKI, hypervolemia or hyperkalemia were excluded. Patients received either N/S or L/R intravenously at a dose of 20 ml/kg body-weight/day. We studied kidney function at discharge and at 30 days, duration of hospitalization, acid-base balance and the need for dialysis. Results We studied 38 patients and 20 were treated with N/S. Kidney function improvement during hospitalization and at 30 days after discharge, was similar between the two groups. Duration of hospitalization was also similar. Anion-gap improvement as expressed with Δanion-gap between discharge and admission day was higher in those patients that received L/R in comparison to those that received N/S and pH increase (ΔpH) was slightly higher in the L/R group. No patient required dialysis. Conclusions Administration of L/R or N/S to patients with prerenal AKI and pre-established CKD had no significant difference in short or long term kidney function but L/R showed a better profile in acid-base balance improvement and Cl- overload in comparison to N/S.
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Management of diabetic ketoacidosis. Intensive Care Med 2023; 49:95-98. [PMID: 36166056 DOI: 10.1007/s00134-022-06894-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/14/2022] [Indexed: 01/24/2023]
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Plasma volume expansion reveals hidden metabolic acidosis in patients with diabetic ketoacidosis. Intensive Care Med Exp 2022; 10:36. [PMID: 36038699 PMCID: PMC9424448 DOI: 10.1186/s40635-022-00464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background Hyperchloremic metabolic acidosis that develops during the treatment of diabetic ketoacidosis is usually attributed to the chloride content of resuscitation fluids. We explored an alternative explanation, namely that fluid-induced plasma volume expansion alters the absolute differences in the concentrations of sodium and chloride (the Na–Cl gap) enough to affect the acid–base balance. We analyzed data from a prospective single-center cohort study of 14 patients treated for diabetic ketoacidosis. All patients received 1 L of 0.9% saline over 30 min on two consecutive days. Blood gases were sampled before and after the infusions. Results The initial plasma volume was estimated to be 25 ± 13% (mean ± SD) below normal on admission to the intensive care unit. At that time, most patients had an increased actual Na–Cl gap, which counteracts acidosis. However, the correction of the plasma volume deficit revealed that these patients would have had a decreased Na–Cl gap upon admission if they had been normovolemic at that time; the estimated “virtual Na–Cl gap” of 29 ± 5 mmol/L was significantly lower than the uncorrected value, which was 39 ± 5 mmol/L (P < 0.001). On Day 2, most patients had a decreased actual Na–Cl gap (33 ± 5 mmol/L), approaching the corrected value on Day 1. Conclusions The hyperchloremic acidosis commonly seen in diabetic ketoacidosis may not be primarily caused by the chloride content of resuscitation fluids but, rather, by the restoration of plasma volume, which reveals the hidden metabolic acidosis caused by a decreased Na–Cl gap. Trial registration Clinical Trials Identifier NCT02172092, registered June 24, 2014, https://www.clinicaltrials.gov/NCT02172092 Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00464-5.
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Kopp BJ, Lenney M, Erstad BL. Balanced Salt Solutions for Critically Ill Patients: Nonplused and Back to Basics. Ann Pharmacother 2022; 56:1365-1375. [PMID: 35392676 DOI: 10.1177/10600280221084380] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES The purpose of this article is to summarize the results of major randomized controlled trials (RCTs) comparing clinical outcomes of critically ill patients treated with normal saline (NS) or balanced salt solutions (BSSs), address discordant results of these studies, and provide direction for future investigations. DATA SOURCES PubMed (2011 to January 2022) with bibliographies of retrieved articles searched for additional articles. STUDY SELECTION AND DATA EXTRACTION RCTs comparing NS and BSSs in critically ill adult patients. DATA SYNTHESIS Recently published large RCTs comparing NS with BSSs in heterogeneous populations of intensive care unit patients did not find significant differences in mortality, despite positive findings in some end points in prior RCTs. However, there were a number of methodologic issues common to the RCTs including: varying study designs and end points, clinician discretion for the majority or all treatments other than the primary intervention fluid, heterogeneous patients with varying levels of acuity, and lack of power to investigate potential subgroup differences. In addition, there were problematic issues related to blinding and use of nonstudy fluids. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Intravenous fluids are a mainstay of supportive care for critically ill patients. Similar to the so-called crystalloid-colloid debate, there has been a long-standing debate among critical care clinicians and researchers concerning the preferred crystalloid solution, NS versus one of the available BSSs. CONCLUSIONS Despite the recent publication of large multicenter RCTs, the preferred resuscitation fluid, NS or a BSS, for critically ill patients is still open for debate, although the available investigations do provide some direction for clinicians and for future investigations.
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Affiliation(s)
- Brian J Kopp
- Surgical-Trauma ICU, Banner-University Medical Center, Tucson, AZ, USA
| | - Morgan Lenney
- PGY2 Critical Care Resident, Banner-University Medical Center, Tucson, AZ, USA
| | - Brian L Erstad
- Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
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Hassan EM, Mushtaq H, Mahmoud EE, Chhibber S, Saleem S, Issa A, Nitesh J, Jama AB, Khedr A, Boike S, Mir M, Attallah N, Surani S, Khan SA. Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state. World J Clin Cases 2022; 10:11702-11711. [PMID: 36405291 PMCID: PMC9669841 DOI: 10.12998/wjcc.v10.i32.11702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/08/2022] Open
Abstract
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity. Despite major advances, reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging. A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle. It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution. Worldwide, there is a lack of large-scale studies that help define how hyperglycemic crises should be managed. This article will provide a comprehensive review of the pathophysiology, diagnosis, and management of DKA-HHS overlap.
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Affiliation(s)
- Esraa Mamdouh Hassan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hisham Mushtaq
- Medicine, St. Vincent's Medical Center, Bridgeport, CT 06606, United States
| | - Esraa Elaraby Mahmoud
- Medicine, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Sherley Chhibber
- Medicine, Mercy Catholic Medical Center, Darby, PA 19025, United States
| | - Shoaib Saleem
- Medicine, Mayo Hospital, Lahore 54000, Punjab, Pakistan
| | - Ahmed Issa
- Medicine, Medical University of the Americas, Nevis, West Indies
| | - Jain Nitesh
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Anwar Khedr
- Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Sydney Boike
- Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Mikael Mir
- Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Medicine & Pharmacology, Texas A&M University Health Science Center, College Station, TX 77843, United States
- Anesthesiolgy, Mayo Clinic, Rochester, MN 55905, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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Lombardo S, Smith MC, Semler MW, Wang L, Dear ML, Lindsell CJ, Freundlich RE, Guillamondegui OD, Self WH, Rice TW. Balanced Crystalloid versus Saline in Adults with Traumatic Brain Injury: Secondary Analysis of a Clinical Trial. J Neurotrauma 2022; 39:1159-1167. [PMID: 35443809 PMCID: PMC9422787 DOI: 10.1089/neu.2021.0465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Balanced crystalloids may improve outcomes compared with saline for some critically ill adults. Lower tonicity of balanced crystalloids could worsen cerebral edema in patients with intracranial pathology. The effect of balanced crystalloids versus saline on clinical outcomes in patients with traumatic brain injury (TBI) requires further study. We planned an a priori subgroup analysis of TBI patients enrolled in the pragmatic, cluster-randomized, multiple-crossover Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (ClinicalTrials.gov: NCT02444988, NCT02547779). Primary outcome was 30-day in-hospital mortality. Secondary outcomes included hospital discharge disposition (home, facility, death). Regression models adjusted for pre-specified baseline covariates compared outcomes. TBI patients assigned to balanced crystalloids (n = 588) and saline (n = 569) had similar baseline characteristics including Injury Severity Score 19 (10); mean maximum head/neck Abbreviated Injury Score, 3.4 (1.0). Isotonic crystalloid volume administered between intensive care unit admission and first of hospital discharge or 30 days was 2037 (3470) mL and 1723 (2923) mL in the balanced crystalloids and saline groups, respectively (p = 0.18). During the study period, 94 (16%) and 82 (14%) patients (16%) died in the balanced crystalloid and saline groups, respectively (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.60 to 1.75; p = 0.913). Patients in the balanced crystalloid group were more likely to die or be discharged to another medical facility (aOR 1.38 [1.02-1.86]; p = 0.04). Overall, balanced crystalloids were associated with worse discharge disposition in critically injured patients with TBI compared with saline. The confidence intervals cannot exclude a clinically relevant increase in mortality when balanced crystalloids are used for patients with TBI.
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Affiliation(s)
- Sarah Lombardo
- Section of Acute Care Surgery, Division of General Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael C. Smith
- Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Robert E. Freundlich
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Oscar D. Guillamondegui
- Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Zhao X, Gu B, Li Q, Li J, Zeng W, Li Y, Guan Y, Huang M, Lei L, Zhong G. Machine learning approach identified clusters for patients with low cardiac output syndrome and outcomes after cardiac surgery. Front Cardiovasc Med 2022; 9:962992. [PMID: 36061544 PMCID: PMC9434347 DOI: 10.3389/fcvm.2022.962992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background Low cardiac output syndrome (LCOS) is the most serious physiological abnormality with high mortality for patients after cardiac surgery. This study aimed to explore the multidimensional data of clinical features and outcomes to provide individualized care for patients with LCOS. Methods The electronic medical information of the intensive care units (ICUs) was extracted from a tertiary hospital in South China. We included patients who were diagnosed with LCOS in the ICU database. We used the consensus clustering approach based on patient characteristics, laboratory data, and vital signs to identify LCOS subgroups. The consensus clustering method involves subsampling from a set of items, such as microarrays, and determines to cluster of specified cluster counts (k). The primary clinical outcome was in-hospital mortality and was compared between the clusters. Results A total of 1,205 patients were included and divided into three clusters. Cluster 1 (n = 443) was defined as the low-risk group [in-hospital mortality =10.1%, odds ratio (OR) = 1]. Cluster 2 (n = 396) was defined as the medium-risk group [in-hospital mortality =25.0%, OR = 2.96 (95% CI = 1.97–4.46)]. Cluster 3 (n = 366) was defined as the high-risk group [in-hospital mortality =39.2%, OR = 5.75 (95% CI = 3.9–8.5)]. Conclusion Patients with LCOS after cardiac surgery could be divided into three clusters and had different outcomes.
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Affiliation(s)
- Xu Zhao
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-sen University, Guangzhou, China
| | - Bowen Gu
- Laboratory of South China Structural Heart Disease, Department of Intensive Care Unit of Cardiovascular Suregery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Qiuying Li
- Laboratory of South China Structural Heart Disease, Department of Intensive Care Unit of Cardiovascular Suregery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Jiaxin Li
- Laboratory of South China Structural Heart Disease, Department of Intensive Care Unit of Cardiovascular Suregery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Weiwei Zeng
- Department of Pharmacy, The Second People's Hospital of Longgang District, Shenzhen, China
| | - Yagang Li
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-sen University, Guangzhou, China
| | - Yanping Guan
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-sen University, Guangzhou, China
| | - Min Huang
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-sen University, Guangzhou, China
| | - Liming Lei
- Laboratory of South China Structural Heart Disease, Department of Intensive Care Unit of Cardiovascular Suregery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangzhou, China
- *Correspondence: Liming Lei
| | - Guoping Zhong
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacology, Sun Yat-sen University, Guangzhou, China
- Guoping Zhong
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Cao A, Bellfi LT, Schoen J, Greiffenstein P, Marr AB, Stuke L, Hunt JP, Pino R, Smith A. Perioperative Fluid Management in Surgical Patients: A Review. Am Surg 2022:31348221121565. [PMID: 35977846 DOI: 10.1177/00031348221121565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intravenous (IV) fluids are one of the most widely prescribed medications. Despite their frequent usage, IV fluids are often not used appropriately. High-quality evidence to guide the surgeon in the perioperative period is sparse. A plethora of choices for IV fluids exists with limited evidence to help guide the surgeon in specific patient populations and situations. To address this, the authors have set out to provide a critical review of commonly used IV fluids to treat surgical patients. Gaps in the existing literature for the surgical population will also be discussed as potential target areas for future research.
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Affiliation(s)
- Alex Cao
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | | | - Jonathan Schoen
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Patrick Greiffenstein
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Alan B Marr
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Lance Stuke
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - John P Hunt
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Richard Pino
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Alison Smith
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
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Zhou FQ. Pyruvate as a Potential Beneficial Anion in Resuscitation Fluids. Front Med (Lausanne) 2022; 9:905978. [PMID: 35991638 PMCID: PMC9382911 DOI: 10.3389/fmed.2022.905978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/15/2022] [Indexed: 12/02/2022] Open
Abstract
There have been ongoing debates about resuscitation fluids because each of the current fluids has its own disadvantages. The debates essentially reflect an embarrassing clinical status quo that all fluids are not quite ideal in most clinical settings. Therefore, a novel fluid that overcomes the limitations of most fluids is necessary for most patients, particularly diabetic and older patients. Pyruvate is a natural potent antioxidant/nitrosative and anti-inflammatory agent. Exogenous pyruvate as an alkalizer can increase cellular hypoxia and anoxia tolerance with the preservation of classic glycolytic pathways and the reactivation of pyruvate dehydrogenase activity to promote oxidative metabolism and reverse the Warburg effect, robustly preventing and treating hypoxic lactic acidosis, which is one of the fatal complications in critically ill patients. In animal studies and clinical reports, pyruvate has been shown to play a protective role in multi-organ functions, especially the heart, brain, kidney, and intestine, demonstrating a great potential to improve patient survival. Pyruvate-enriched fluids including crystalloids and colloids and oral rehydration solution (ORS) may be ideal due to the unique beneficial properties of pyruvate relative to anions in contemporary existing fluids, such as acetate, bicarbonate, chloride, citrate, lactate, and even malate. Preclinical studies have demonstrated that pyruvate-enriched saline is superior to 0.9% sodium chloride. Moreover, pyruvate-enriched Ringer’s solution is advantageous over lactated Ringer’s solution. Furthermore, pyruvate as a carrier in colloids, such as hydroxyethyl starch 130/0.4, is more beneficial than its commercial counterparts. Similarly, pyruvate-enriched ORS is more favorable than WHO-ORS in organ protection and shock resuscitation. It is critical that pay attention first to improving abnormal saline with pyruvate for ICU patients. Many clinical trials with a high dose of intravenous or oral pyruvate were conducted over the past half century, and results indicated its effectiveness and safety in humans. The long-term instability of pyruvate aqueous solutions and para-pyruvate cytotoxicity is not a barrier to the pharmaceutical manufacturing of pyruvate-enriched fluids for ICU patients. Clinical trials with sodium pyruvate-enriched solutions are urgently warranted.
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Catahay JA, Polintan ET, Casimiro M, Notarte KI, Velasco JV, Ver AT, Pastrana A, Macaranas I, Patarroyo-Aponte G, Lo KB. Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis. Heart Lung 2022; 54:74-79. [PMID: 35358905 DOI: 10.1016/j.hrtlng.2022.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Current guidelines suggest the use of isotonic saline (IS) infusion as the preferred resuscitation fluid in the management of diabetic ketoacidosis (DKA). However, balanced electrolyte solutions (BES) have been proposed as an alternative due to a lower propensity to cause hyperchloremic metabolic acidosis. Evidence regarding the use of BES in DKA remains limited. OBJECTIVES To determine if the use of BES in fluid resuscitation leads to faster resolution of DKA compared to IS. METHODS The study involves a comprehensive search of literature from PubMed, Cochrane CENTRAL, Google Scholar, and Science Direct of clinical trials addressing the use of BES vs IS in fluid resuscitation in DKA. The time to resolution of DKA was examined as the primary endpoint. Pooled hazard ratios (HR) and Mean Difference (MD) in hours with their 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS The literature search included 464 studies that were screened individually. A total of 9 studies were identified but 6 studies were excluded due to irrelevance in the outcome of interest and target population. The pooled hazard ratio HR significantly revealed 1.46 [1.10 to 1.94] (p = 0.009) with 12% heterogeneity while MD was -3.02 (95% CI -6.78-0.74; p = 0.12) with heterogeneity of 85%. CONCLUSION Considering the evidence from pooled small randomized trials with moderate overall certainty of evidence, the use of BES in DKA was associated with faster rates of DKA resolution compared to IS.
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Affiliation(s)
| | | | - Michael Casimiro
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Kin Israel Notarte
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | | | | | - Adriel Pastrana
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Imee Macaranas
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Gabriel Patarroyo-Aponte
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, USA
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Dhatariya KK. The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care. Diabet Med 2022; 39:e14788. [PMID: 35224769 DOI: 10.1111/dme.14788] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/11/2022] [Indexed: 12/20/2022]
Abstract
This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14 mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05 units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medicine School, University of East Anglia, Norwich, UK
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Semler MW. Intravenous Fluids-A Test Case for Learning Health Systems. JAMA Netw Open 2022; 5:e2210054. [PMID: 35503223 DOI: 10.1001/jamanetworkopen.2022.10054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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35
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Seibold J, Ramshorn-Zimmer A, Ebert T, Tönjes A. Diabetologische Notfälle im Krankenhaus. DIABETOLOGE 2022. [DOI: 10.1007/s11428-022-00875-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Finfer S, Micallef S, Hammond N, Navarra L, Bellomo R, Billot L, Delaney A, Gallagher M, Gattas D, Li Q, Mackle D, Mysore J, Saxena M, Taylor C, Young P, Myburgh J. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med 2022; 386:815-826. [PMID: 35041780 DOI: 10.1056/nejmoa2114464] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether the use of balanced multielectrolyte solution (BMES) in preference to 0.9% sodium chloride solution (saline) in critically ill patients reduces the risk of acute kidney injury or death is uncertain. METHODS In a double-blind, randomized, controlled trial, we assigned critically ill patients to receive BMES (Plasma-Lyte 148) or saline as fluid therapy in the intensive care unit (ICU) for 90 days. The primary outcome was death from any cause within 90 days after randomization. Secondary outcomes were receipt of new renal-replacement therapy and the maximum increase in the creatinine level during ICU stay. RESULTS A total of 5037 patients were recruited from 53 ICUs in Australia and New Zealand - 2515 patients were assigned to the BMES group and 2522 to the saline group. Death within 90 days after randomization occurred in 530 of 2433 patients (21.8%) in the BMES group and in 530 of 2413 patients (22.0%) in the saline group, for a difference of -0.15 percentage points (95% confidence interval [CI], -3.60 to 3.30; P = 0.90). New renal-replacement therapy was initiated in 306 of 2403 patients (12.7%) in the BMES group and in 310 of 2394 patients (12.9%) in the saline group, for a difference of -0.20 percentage points (95% CI, -2.96 to 2.56). The mean (±SD) maximum increase in serum creatinine level was 0.41±1.06 mg per deciliter (36.6±94.0 μmol per liter) in the BMES group and 0.41±1.02 mg per deciliter (36.1±90.0 μmol per liter) in the saline group, for a difference of 0.01 mg per deciliter (95% CI, -0.05 to 0.06) (0.5 μmol per liter [95% CI, -4.7 to 5.7]). The number of adverse and serious adverse events did not differ meaningfully between the groups. CONCLUSIONS We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of BMES than with saline. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; PLUS ClinicalTrials.gov number, NCT02721654.).
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Affiliation(s)
- Simon Finfer
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Sharon Micallef
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Naomi Hammond
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Leanlove Navarra
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Rinaldo Bellomo
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Laurent Billot
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Anthony Delaney
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Martin Gallagher
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - David Gattas
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Qiang Li
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Diane Mackle
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Jayanthi Mysore
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Manoj Saxena
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Colman Taylor
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - Paul Young
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
| | - John Myburgh
- From the George Institute for Global Health and the University of New South Wales (S.F., S.M., N.H., L.B., A.D., M.G., Q.L., J. Mysore, M.S., C.T., J. Myburgh), the Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital (N.H., A.D.), the Northern Clinical School (A.D.) and the Central Clinical School (D.G.), University of Sydney, the Intensive Care Unit, Royal Prince Alfred Hospital (D.G.), the Department of Intensive Care, St. George Hospital (M.S., J. Myburgh), and the Intensive Care Unit, Bankstown Hospital (M.S.), Sydney, and the Intensive Care Unit, Austin Hospital (R.B.), the Department of Intensive Care, Royal Melbourne Hospital (R.B.), the Department of Critical Care, University of Melbourne (R.B., P.Y.), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R.B., P.Y.), Melbourne, VIC - all in Australia; the School of Public Health, Imperial College London, London (S.F.); and the Medical Research Institute of New Zealand (L.N., D.M., P.Y.) and the Department of Intensive Care, Wellington Regional Hospital (L.N., P.Y.) - both in Wellington
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Aldhaeefi M, Aldardeer NF, Alkhani N, Alqarni SM, Alhammad AM, Alshaya AI. Updates in the Management of Hyperglycemic Crisis. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 2:820728. [PMID: 36994324 PMCID: PMC10012093 DOI: 10.3389/fcdhc.2021.820728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/24/2021] [Indexed: 12/14/2022]
Abstract
Diabetes mellitus (DM) affects the metabolism of primary macronutrients such as proteins, fats, and carbohydrates. Due to the high prevalence of DM, emergency admissions for hyperglycemic crisis, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are fairly common and represent very challenging clinical management in practice. DKA and HHS are associated with high mortality rates if left not treated. The mortality rate for patients with DKA is < 1% and ~ 15% for HHS. DKA and HHS have similar pathophysiology with some few differences. HHS pathophysiology is not fully understood. However, an absolute or relative effective insulin concentration reduction and increased in catecholamines, cortisol, glucagon, and growth hormones represent the mainstay behind DKA pathophysiology. Reviewing the patient’s history to identify and modify any modifiable precipitating factors is crucial to prevent future events. The aim of this review article is to provide a review of the DKA, and HHS management based on the most recently published evidence and to provide suggested management pathway of DKA of HHS management in practice.
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Affiliation(s)
- Mohammed Aldhaeefi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- *Correspondence: Mohammed Aldhaeefi,
| | - Namareq F. Aldardeer
- Department of Pharmacy Services, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Nada Alkhani
- Department of Pharmacy Services, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Shatha Mohammed Alqarni
- Doctor of Pharmacy Program, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah M. Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Department of Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman I. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Saline Compared to Balanced Crystalloid in Patients With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor 2022; 4:e0613. [PMID: 35018349 PMCID: PMC8740878 DOI: 10.1097/cce.0000000000000613] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This systematic review and meta-analysis compared the use of saline to balanced crystalloid for fluid resuscitation in patients with diabetic ketoacidosis (DKA). DATA SOURCES We searched databases including Medline, Embase, and the Cochrane registry. STUDY SELECTION We included randomized controlled trials (RCTs) that compared saline to balanced crystalloid in patients with DKA. DATA EXTRACTION We pooled estimates of effect using relative risk for dichotomous outcomes and mean differences (MDs) for continuous outcomes, both with 95% CIs. We assessed risk of bias for included RCTs using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluation methodology. DATA SYNTHESIS We included eight RCTs (n = 482 patients). Both time to DKA resolution (MD, 3.51 hr longer; 95% CI, 0.90 longer to 6.12 longer; moderate certainty) and length of hospital stay (MD, 0.89 d longer in saline group; 95% CI, 0.34 longer to 1.43 d longer; moderate certainty) are probably longer in the saline group compared with the balanced crystalloid group, although for the latter, the absolute difference (under 1 d) is small. Post-resuscitation serum chloride level may be higher (MD, 1.62 mmol/L higher; 95% CI, 0.40 lower to 3.64 higher; low certainty), and post-resuscitation serum bicarbonate is probably lower (MD, 1.50 mmol/L; 95% CI, 2.33 lower to 0.67 lower; moderate certainty) in those receiving saline. CONCLUSIONS In patients with DKA, the use of saline may be associated with longer time to DKA resolution, higher post-resuscitation serum chloride levels, lower post-resuscitation serum bicarbonate levels, and longer hospital stay compared with balanced crystalloids. Pending further data, low to moderate certainty data support using balanced crystalloid over saline for fluid resuscitation in patients with DKA.
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Zheng DJ, Iskander S, Vujcic B, Amin K, Valani R, Yan JW. A comparison of adult diabetic ketoacidosis treatment protocols from Canadian emergency departments. Can J Diabetes 2021; 46:269-276.e2. [DOI: 10.1016/j.jcjd.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/05/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
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Spiegel MC, Simpson AN, Philip A, Bell CM, Nadig NR, Ford DW, Goodwin AJ. Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing. Int J Med Inform 2021; 156:104619. [PMID: 34673308 DOI: 10.1016/j.ijmedinf.2021.104619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/01/2021] [Accepted: 10/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.
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Affiliation(s)
- Michelle C Spiegel
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Annie N Simpson
- Department of Health Care Leadership and Management, Medical University of South Carolina, Charleston, SC, United States
| | - Achsah Philip
- Department of Information Solutions, Medical University of South Carolina, Charleston, SC, United States
| | - Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, United States
| | - Nandita R Nadig
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Dee W Ford
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
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Fluid management in diabetic ketoacidosis: new tricks for old dogs? Intensive Care Med 2021; 47:1312-1314. [PMID: 34608527 DOI: 10.1007/s00134-021-06527-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
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Ramanan M, Attokaran A, Murray L, Bhadange N, Stewart D, Rajendran G, Pusapati R, Petty M, Garrett P, Kruger P, Peake S, Billot L, Venkatesh B. Sodium chloride or Plasmalyte-148 evaluation in severe diabetic ketoacidosis (SCOPE-DKA): a cluster, crossover, randomized, controlled trial. Intensive Care Med 2021; 47:1248-1257. [PMID: 34609547 DOI: 10.1007/s00134-021-06480-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/09/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine whether treatment with Plasmalyte-148 (PL) compared to sodium chloride 0.9% (SC) results in faster resolution of diabetic ketoacidosis (DKA) and whether the acetate in PL potentiates ketosis. METHODS We conducted a cluster, crossover, open-label, randomized, controlled Phase 2 trial at seven hospitals in adults admitted to intensive care unit (ICU) with severe DKA with hospital randomised to PL or SC as fluid therapy. The primary outcome, DKA resolution, was defined as a change in base excess to ≥ - 3 mEq/L at 48 h. RESULTS Ninety-three patients were enrolled with 90 patients included in the modified-intention-to-treat population (PL n = 48, SC n = 42). At 48 h, mean fluid administration was 6798 ± 4850 ml vs 6574 ± 3123 ml, median anion gap 6 mEq/L (IQR 5-7) vs 7 mEq/L (IQR 5-7) and median blood ketones 0.3 mmol/L (IQR 0.1-0.5) vs 0.3 (IQR 0.1-0.5) in the PL and SC groups. DKA resolution at 48 h occurred in 96% (PL) and 86% (SC) of patients; odds ratio 3.93 (95% CI 0.73-21.16, p = 0.111). At 24 h, DKA resolution occurred in 69% (PL) and 36% (SC) of patients; odds ratio 4.24 (95% CI 1.68-10.72, p = 0.002). The median ICU and hospital lengths of stay were 49 h (IQR 23-72) vs 55 h (IQR 41-80) and 81 h (IQR 58-137) vs 98 h (IQR 65-195) in the PL and SC groups. CONCLUSION Plasmalyte-148, compared to sodium chloride 0.9%, may lead to faster resolution of metabolic acidosis in patients with DKA without an increase in ketosis. These findings need confirmation in a large, Phase 3 trial.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, McKean Street, Caboolture, QLD, 4510, Australia. .,Adult Intensive Care Services, The Prince Charles Hospital, Rode Road, Chermside, QLD, 4032, Australia. .,The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia. .,School of Medicine, University of Queensland, Sir Fred Schonell Drive, St Lucia, QLD, 4072, Australia.
| | - Antony Attokaran
- Intensive Care Unit, Rockhampton Hospital, Canning Street, Rockhampton, QLD, 4700, Australia
| | - Lauren Murray
- Intensive Care Unit, Sunshine Coast University Hospital, Doherty Street, Birtinya, QLD, 4575, Australia
| | - Neeraj Bhadange
- Intensive Care Unit, Ipswich Hospital, Chelmsford Avenue, Ipswich, QLD, 4305, Australia
| | - David Stewart
- Intensive Care Unit, Queen Elizabeth-2 Jubilee Hospital, Kessels Road, Coopers Plains, QLD, 4108, Australia
| | - Gokulnath Rajendran
- Intensive Care Unit, Mackay Base Hospital, Bridge Road, Mackay, QLD, 4741, Australia
| | - Raju Pusapati
- Intensive Care Unit, Hervey Bay Hospital, Urraween Road, Pialba, QLD, 4655, Australia
| | - Melissa Petty
- Intensive Care Unit, Caboolture Hospital, McKean Street, Caboolture, QLD, 4510, Australia
| | - Peter Garrett
- Intensive Care Unit, Sunshine Coast University Hospital, Doherty Street, Birtinya, QLD, 4575, Australia
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD, 4102, Australia
| | - Sandra Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville Road, Woodville South, South Australia, 5011, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia.,Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Woolloongabba, QLD, Australia
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Erstad BL. Normal saline or balanced salt solutions for fluid administration with a focus on critical care and emergency medicine settings. Am J Health Syst Pharm 2021; 79:199-203. [PMID: 34351364 DOI: 10.1093/ajhp/zxab319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
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Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State. J Emerg Med 2021; 61:365-375. [PMID: 34256953 DOI: 10.1016/j.jemermed.2021.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations. OBJECTIVE This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state. DISCUSSION Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit. CONCLUSIONS Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - George C Willis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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45
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Li Q, Lv L, Chen Y, Zhou Y. Early prediction models for prognosis of diabetic ketoacidosis in the emergency department: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26113. [PMID: 34032754 PMCID: PMC8154382 DOI: 10.1097/md.0000000000026113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the most serious complications after diabetes poor control, which seriously threatens human life, health, and safety. DKA can rapidly develop within hours or days leading to death. Early evaluation of the prognosis of DKA patients and timely and effective intervention are very important to improve the prognosis of patients. The combination of several variables or characteristics is used to predict the poor prognosis of DKA, which can allocate resources reasonably, which is beneficial to the early classification intervention and clinical treatment of the patients. METHODS For the acquisition of required data of eligible prospective/retrospective cohort study or randomized controlled trials (RCTs), we will search for publications from PubMed, Web of science, EMBASE, Cochrane Library, Google scholar, China national knowledge infrastructure (CNKI), Wanfang and China Science and Technology Journal Database (VIP). Two independent reviewers will read the full English text of the articles, screened and selected carefully, removing duplication. Then we evaluate the quality and analyses data by Review Manager (V.5.4). Results data will be pooled and meta-analysis will be conducted if there's 2 eligible studies considered. RESULTS This systematic review and meta-analysis will evaluate the value of the prediction models for the prognosis of DKA in the emergency department. CONCLUSIONS This systematic review and meta-analysis will provide clinical basis for predicting the prognosis of DKA. It helps us to understand the value of predictive models in evaluating the early prognosis of DKA. The conclusions drawn from this study may be beneficial to patients, clinicians, and health-related policy makers. STUDY REGISTRATION NUMBER INPLASY202150023.
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Affiliation(s)
- Qin Li
- Department of Emergency Medicine, Emergency Medical Laboratory
- School of Nursing, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lin Lv
- Department of Emergency Medicine, Emergency Medical Laboratory
| | - Yao Chen
- Department of Emergency Medicine, Emergency Medical Laboratory
| | - Yiwu Zhou
- Department of Emergency Medicine, Emergency Medical Laboratory
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Abstract
PURPOSE OF REVIEW An increasing number of patients with endocrine disorders will present to the operating rooms. In this review, we outline the common endocrine disorders that the anesthesiologist may face in the perioperative time span, review the controversies in optimal management, as well as summarize the recent literature for the management of these complex patients. RECENT FINDINGS Perioperative management of pheochromocytoma and paraganglioma has been facilitated by improved medical management and the adoption of minimally invasive surgical techniques. An improved understanding of the sequelae of carcinoid syndrome has resulted in safer perioperative management. Perioperative glycemic management requires a fundamental understanding of perioperative fluid resuscitation and adverse events associated with the new generation oral hyperglycemic agents to prevent avoidable complications. SUMMARY Endocrine disorders will commonly present in the perioperative time period and the anesthesiologist plays a critical role in achieving good operative outcomes.
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47
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Long B, Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management. Am J Emerg Med 2021; 44:157-160. [PMID: 33626481 DOI: 10.1016/j.ajem.2021.02.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL. OBJECTIVE This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians. DISCUSSION EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology. CONCLUSIONS Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL 60612, United States of America
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48
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Moritz ML, Ayus JC. 0.9% saline and balance crystalloids in acute ill patients: Trading one problem for another. J Crit Care 2021; 63:254-256. [PMID: 33608168 DOI: 10.1016/j.jcrc.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Michael L Moritz
- UPMC Children's Hospital of Pittsburgh, USA; Division of Nephrology, Department of Pediatrics, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Juan C Ayus
- University of California, Irvine, Department of Nephrology, Orange, CA, USA
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