Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

• Published in: Frontiers in endocrinology (Lausanne) 2017-06, Vol.8, p.106-106
• Main Authors: Tran, Tara T T, Pease, Anthony, Wood, Anna J, Zajac, Jeffrey D, Mårtensson, Johan, Bellomo, Rinaldo, Ekinci, Elif I I
• Format: Article
• Language: English
• Subjects: diabetes; diabetic ketoacidosis; Endocrinology; hypoglycemia; hypokalemia; insulin; rehydration
• ISSN: 1664-2392; 1664-2392
• DOI: 10.3389/fendo.2017.00106

Diabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs). To review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes. Ovid Medline searches were conducted with limits "all adult" and published between "1973 to current" applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers' assessment of title, abstract, and availability. A total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over "sliding scale" insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH