scholarly journals Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

BMJ ◽  
2019 ◽  
pp. l1114 ◽  
Author(s):  
Esra Karslioglu French ◽  
Amy C Donihi ◽  
Mary T Korytkowski
Keyword(s):  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Hospital Readmissions ◽  
Acute Management ◽  
Careful Monitoring ◽  
Acute Presentation ◽  
Intravenous Insulin ◽  
Patients With Diabetes ◽  
Life Threatening ◽  
Hyperosmolar Hyperglycemic Syndrome

Abstract Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. 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). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

Evaluation of Early Administration of Insulin Glargine in the Acute Management of Diabetic Ketoacidosis

2021 ◽  
Vol 17 ◽  
Author(s):  
Adham Mohamed ◽  
Jeannette Ploetz ◽  
Majdi S Hamarshi
Keyword(s):  
Insulin Glargine ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Acute Management ◽  
Early Administration ◽  
Intravenous Insulin ◽  
Serum Bicarbonate Level ◽  
The Mean ◽  
Mean Blood Glucose

Background: Few studies have evaluated the early use of insulin glargine in the management of diabetic ketoacidosis (DKA) patients. Early insulin glargine use in DKA was safe and associated with a trend towards faster DKA resolution. Objectives: To evaluate the efficacy and safety of early insulin glargine administration for acute management of DKA in critically ill patients. Methods: This single-center retrospective cohort study included patients, who were >18 years of age with DKA, admitted to the intensive care unit (ICU) for at least 12 h, and received intravenous insulin infusion for at least 6 h. The primary endpoint was the association between the time to insulin glargine administration and time to DKA resolution. Linear and logistic regression analyses were performed. Results: Of the 913 patients evaluated, 380 were included in the study. The overall mean age was 45±17 years, 196 (51.6%) were female, and 262 (70%) patients had type 1 diabetes mellitus. The mean blood glucose level was 584.9±210 mg/dL, pH was 7.16±0.17, anion gap was 28.17±6.9 mEq/L, and serum bicarbonate level was 11.19±5.72 mEq/L. Every 6-h delay in insulin glargine administration was associated with a 26-min increase in time to DKA resolution (95% confidence interval [CI], 14.76–37.44; p<0.0001), 3.2-h increase in insulin infusion duration (95% CI, 28.8–36; p<0.0001), and 6.5-h increase in ICU LOS (95% CI, 5.04–7.92; p<0.0001). Conclusion: Early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and shorter duration of insulin infusion.

Safety and Efficacy of Various Intravenous Insulin Infusion Rates in Patients With and Without Diabetes Presenting With Hypertriglyceridemia

2022 ◽  
pp. 106002802110701
Author(s):  
Francisco Ibarra ◽  
Kaitlyn Loi ◽  
Ann W. Vu
Keyword(s):  
Medical History ◽  
Insulin Infusion ◽  
Case Reports ◽  
Retrospective Chart Review ◽  
Acute Management ◽  
Past Medical History ◽  
Safety And Efficacy ◽  
Intravenous Insulin ◽  
Number Of Patients ◽  
History Of

Background The use of IV insulin infusions in the acute management of hypertriglyceridemia has only been evaluated in small observational studies and case reports. Objective To evaluate the safety and efficacy of IV insulin infusions in the acute management of hypertriglyceridemia. Methods This was a retrospective chart review of adult patients who received an IV insulin infusion for the acute management of hypertriglyceridemia. The primary efficacy and safety outcomes were the number of patients who achieved a triglyceride level <500 mg/dL and experienced hypoglycemia (<70 mg/dL), respectively. A subgroup analysis was performed to compare outcomes between patients with and without diabetes, in addition to the IV insulin infusion rate received. Results In the total population (n = 51), there were no statistically significant differences between the insulin intensity groups in the number of patients who achieved TG levels <500 mg/dL. Compared to patients with a past medical history of diabetes, more patients without a past medical history of diabetes achieved triglyceride levels <500 mg/dL (14% vs 53%, respectively, P < 0.001). The number of hypoglycemic events observed in patients with and without a past medical history of diabetes were 5 (14%) and 4 (27%), respectively ( P = 0.023). Conclusion and Relevance Our findings suggest that patients who present with lower initial TG levels are more likely to achieve TG levels <500 mg/dL. To minimize the risk of hypoglycemia providers should consider prescribing a concomitant dextrose infusion and limiting IV insulin infusion rates ≤ 0.075 units/kg/h.

Effectiveness of low-dose continuous intravenous insulin infusion in diabetic ketoacidosis

1977 ◽  
Vol 91 (5) ◽  
pp. 701-705 ◽  
Author(s):  
George A. Edwards ◽  
Edward C. Kohaut ◽  
Barbara Wehring ◽  
L. Leighton Hill
Keyword(s):  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Low Dose ◽  
Intravenous Insulin

Case of sodium–glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis

2021 ◽  
Vol 14 (8) ◽  
pp. e235953 ◽  
Author(s):  
Huei Li Yeoh ◽  
Marilyn Lee ◽  
Woei Jack Pan ◽  
Hean Yee Ong
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Anion Gap ◽  
Subcutaneous Insulin ◽  
Intravenous Insulin ◽  
High Dependency ◽  
Sodium Glucose Cotransporter ◽  
Sliding Scale ◽  
Basal Bolus

Following non-elective orthopaedic surgery, a 61-year-old man with poorly controlled type 2 diabetes mellitus on empagliflozin developed high anion gap metabolic acidosis in the high-dependency unit. Metabolic acidosis persisted despite intravenous sodium bicarbonate, contributing to tachycardia and a run of non-sustained ventricular tachycardia. He was euglycaemic throughout hospital admission. Investigations revealed elevated urine and capillary ketones, and a diagnosis of sodium–glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis was made. He was treated with an intravenous sliding scale insulin infusion and concurrent dextrose 5% with potassium chloride. Within 24 hours of treatment, his arterial pH, anion gap and serum bicarbonate levels normalised. After a further 12 hours, the intravenous insulin infusion was converted to a basal/bolus regimen of subcutaneous insulin, and he was transferred to the general ward. He was discharged well on subcutaneous insulin 6 days postoperatively.

Euglycemic Diabetic Ketoacidosis in a Diabetic Patient Treated with SGLT2 Inhibitor

2021 ◽  
Vol 6 (1) ◽  
Author(s):  
Lavrynenko O ◽  
◽  
Santos H ◽  
Garza A ◽  
Qazi R ◽  
...  
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Glucose Transporter ◽  
Sglt2 Inhibitor ◽  
Anion Gap ◽  
Laboratory Evaluation ◽  
Intravenous Insulin ◽  
Glucose Transporter 2 ◽  
Life Threatening ◽  
History Of

Diabetic Ketoacidosis (DKA) is a life - threatening complication and must be diagnosed and treated promptly and aggressively. The classic triad of DKA is hyperglycemia (Blood Glucose (BG) >250mg/dl; anion gap metabolic acidosis (pH <7.30 and bicarbonate <18mEq/L); and ketonemia. With Food and Drug Administration (FDA) approval of the sodium - glucose transporter 2 inhibitors (SGLT2i), DKA can occur with BG levels below 200mg/dl and has been defined as Euglycemic DKA (EuDKA). Due to the absence of hyperglycemia, the diagnosis of EuDKA is challenging and often delayed. This 60-year-old diabetic male, treated with Empagliflozin and pioglitazone, presented with diarrhea and abdominal pain, which started 20 days ago. He was admitted with dehydration and diagnosis of colitis. On admission laboratory evaluation revealed metabolic acidosis with elevated anion gap of 18mEq/L, bicarbonate of 19mEq/L, and BG of 146mg/dL. There was no history of ingestion of alcohol, salicylates, methanol, ethylene glycol and nothing to suggest lactic acidosis. The plasma creatinine was 0.79mg/dl. On the following day, he developed an increase in the anion gap to 22mEq/L and further decrease in bicarbonate to 13mEq/L, and serum ketones were detected. The patient was treated for EuDKA in ICU with intravenous insulin, dextrose (to prevent hypoglycemia), and normal saline with resolution of his symptoms and EuDKA in 3 days. With the widespread use of SGLT2i, physicians need to have a high suspicion of EuDKA in patients who present with an unexplained anion gap acidosis without or only modest elevation in BG concentration.

Treatment of Diabetic Ketoacidosis With Intravenous U-500 Insulin in a Patient With Rabson-Mendenhall Syndrome: A Case Report

2016 ◽  
Vol 30 (4) ◽  
pp. 468-475 ◽  
Author(s):  
Megan M. Moore ◽  
Abby M. Bailey ◽  
Alexander H. Flannery ◽  
Regan A. Baum
Keyword(s):  
Insulin Resistance ◽  
Case Report ◽  
Blood Glucose ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Genetic Disorder ◽  
Regular Insulin ◽  
Control Blood Glucose ◽  
Intravenous Insulin ◽  
High Doses

Rabson-Mendenhall syndrome is a rare genetic disorder resulting from mutations in the insulin receptor and is associated with high degrees of insulin resistance. These patients are prone to complications secondary to their hyperglycemia including diabetic ketoacidosis (DKA). We report the case of a 19-year-old male with Rabson-Mendenhall syndrome presenting with DKA who required doses of up to 500 U/h (10.6 U/kg/h) of insulin. The patient’s insulin infusion was originally compounded with U-100 regular insulin, although to minimize volume, the product was compounded with U-500 insulin. The DKA eventually resolved requiring infusion rates ranging from 400 to 500 U/h. Although numerous opportunities for medication errors exist with the use of U-500 insulin, this case outlines the safe use of concentrated intravenous insulin when clinically indicated for patients requiring extremely high doses of insulin to control blood glucose.

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