This is not considered to be a serious complication and usually resolves spontaneously in a few days.198 No evidence supports the use of colloid solutions, balanced electrolyte solutions (such as Plasma-Lyte), or Ringer’s lactate in place of 0.9% sodium chloride solution in the management of diabetic ketoacidosis.60 In one RCT conducted at two institutions, 57 patients admitted with diabetic ketoacidosis were randomly assigned to receive fluid resuscitation with 0.9% sodium chloride or Ringer’s lactate. The consensus among these reviewers was that an emphasis was needed on the patient and family experience of decompensated diabetes as well as on prevention of recurrent episodes. This study will provide additional information on use of long acting insulin preparations early in the course of treatment for diabetic ketoacidosis.7475 It is scheduled to be completed in November 2019. In addition, resources should be directed toward the education of primary care providers and school personnel so that they can identify signs and symptoms of uncontrolled diabetes and so that new-onset diabetes can be diagnosed at an earlier time. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). More frequent blood glucose testing ranging from every 30 min to every 2 h is required for patients receiving intravenous insulin. Standards of Medical Care in Diabetes—2019. Patients are usually severely volume depleted with orthostatic hypotension. Transition to subcutaneous glargine and glulisine resulted in similar glycemic control compared with NPH and regular insulin; however, treatment with basal bolus was associated with a lower rate of hypoglycemic events (15%) than the rate in those treated with NPH and regular insulin (41%) (55). The management of both diabetic ketoacidosis and HHS includes fluids (usually administered intravenously), electrolytes, and insulin. There should be a standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol to immediately address blood glucose levels of <70 mg/dL (3.9 mmol/L), as well as individualized plans for preventing and treating hypoglycemia for each patient. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548. The ADA generally recommends 250-500 mL/h (after the first hour) in adult patients without cardiac or renal compromise, advanced liver disease, and other states of fluid overload. 4. For patients continuing regimens with concentrated insulin (U-200, U-300, or U-500) in the inpatient setting, it is important to ensure the correct dosing by utilizing an individual pen and cartridge for each patient, meticulous pharmacist supervision of the dose administered, or other means (44,45). Compared with baseline, two such studies found that hypoglycemic events fell by 56% to 80% (57,58). ADA and UK guidelines for HHS management both recommend at least 1 L of normal saline during the first hour, followed by adjustment of the infusion rate on the basis of the patient’s hemodynamic and electrolyte status and the achievement of a positive fluid balance. Precipitating factors include pneumonia (40–60%) and urinary tract infections (5–16%) or other acute conditions such as cerebrovascular disease, myocardial infarction, or trauma.32051 The risk of HHS increases in settings of inadequate fluid intake due to altered thirst mechanisms with aging or inability to access fluids.51, Table 1 and table 2 outline diagnostic criteria for diabetic ketoacidosis and HHS as recommended by the American Diabetes Association (ADA), Joint British Diabetes Societies for Inpatient Care, and American Association of Clinical Endocrinologists. Hyperkalemia can result from overly aggressive potassium replacement, particularly in patients with underlying renal dysfunction.5567 Hypoglycemia can result from overly aggressive insulin infusions, insufficient frequency of blood glucose monitoring, or failure to add dextrose to intravenous fluids when blood glucose concentrations approach 13.9 mmol/L (250 mg/dL).5556, In a retrospective review comparing 8550 adult patients with diabetic ketoacidosis admitted to an intensive care unit where blood glucose was corrected to 10 mmol/L (180 mg/dL) or lower or to above 10 mmol/L (180 mg/dL) within 24 hours, those in the latter group had less hypoglycemia, hypokalemia, and hypo-osmolality, with lower mortality.97 However, the fact that these complications still occurred in approximately 25% of patients treated with standardized protocols suggests the need to monitor electrolytes and blood glucose concentrations no less often than every two hours while intravenous insulin infusions are continued. 15.4 Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Thank you for your interest in spreading the word about Diabetes Care. © 2020 by the American Diabetes Association. Joint British Diabetes Societies Inpatient Care Group. Adherance to protocol during the acute management of diabetic ketoacidosis: would specialist involvement lead to better outcomes? It is also important to treat any correctable underlying cause of DKA such as sepsis. Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients and noncritically ill patients. Regarding enteral nutritional therapy, diabetes-specific formulas appear to be superior to standard formulas in controlling postprandial glucose, A1C, and the insulin response (60). 15.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. For patients receiving continuous peripheral or central parenteral nutrition, human regular insulin may be added to the solution, particularly if >20 units of correctional insulin have been required in the past 24 h. A starting dose of 1 unit of human regular insulin for every 10 g dextrose has been recommended (65), to be adjusted daily in the solution. Similarly, adequate supervision and staff education in long-term facilities may prevent many of the admissions for HHS due to dehydration among elderly individuals who are unable to recognize or treat this evolving condition. 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If CSII is to be used, hospital policy and procedures delineating guidelines for CSII therapy, including the changing of infusion sites, are advised (63). We screened and reviewed more than 200 articles in the preparation of this manuscript. Cerebral edema, which occurs in ∼0.3–1.0% of DKA episodes in children, is extremely rare in adult patients during treatment of DKA. In one study, 84% of patients with an episode of “severe hypoglycemia” (defined as <40 mg/dL [2.2 mmol/L]) had a prior episode of hypoglycemia (<70 mg/dL [3.9 mmol/L]) during the same admission (55).

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