Diabetic Ketoacidosis Treatments Vary Widely Among Hospitals in Denmark

Management practices for treating diabetic ketoacidosis (DKA) vary widely among 59 internal medicine departments in Denmark, according to results of a questionnaire-based study in press in an upcoming issue of Diabetes Research and Clinical Practice.

The study identified 24 different insulin regimens and 21 fluid protocols used at the responding departments (Diab. Res. Clin. Pract. 2006 [Epub doi:10.1016/j.diabres.2006.10.013]). “In many cases, the treatment routines employed are not supported by evidence from clinical trials,” wrote lead author Dr. Otto M. Henriksen of the endocrine section at Bispebjerg Hospital, University of Copenhagen, and colleagues.

Overall, 32% of departments managed all patients with DKA in an intensive care unit, whereas 22% used a general medical unit and 32% used an acute medical admission unit.

Most respondents administered an initial regular insulin dose of 10–20 U (median, 16 U) followed by a lower-dose hourly administration of 4–10 U/hour (median, 6 U/hour) of regular insulin. The most common criterion for stopping intensive insulin was resolution of acidosis, used by 76% of departments, followed by the ability to eat and drink (42%), resolution of ketosis (31%), and near-normoglycemia (25%); 53% waited until patients attained at least two of these individual criteria.

Almost all of the respondents used isotonic saline for hydration; 83% administered separate potassium infusions of isotonic potassium-sodium-chloride, and 10% used isotonic potassium chloride.

The recommended fluid administration volumes for the first 8 hours of treatment ranged from 3,750 to 7,700 mL, with a median of 4,800 mL. A mean of 44% of the total volume was derived from potassium supplementation (range, 29%–56%).

More than two-thirds of departments relied on degree of acidosis alone to determine bicarbonate use; 36% used an arterial pH below 7.1 as their threshold to initiate treatment. Another 11% of departments supplemented degree of acidosis with clinical criteria.

In terms of acidosis monitoring, 39% of departments used arterial punctures, 30% used venous blood samples, and 20% used an interchangeable method. Ketosis was most often monitored using a urine dipstick (77%).

Rates of serious complications within the prior 5 years, which were based solely on respondents' recollections, were significantly lower than would be expected from a national registry and included five deaths, four cerebral edemas, and three thromboembolic events.

“The results do suggest that treatment of DKA is perceived as relatively uncomplicated regardless of routine management guidelines,” the researchers concluded. They proposed that national, evidence-based guidelines could reduce durations of hospitalization and increase the cost-effectiveness of DKA treatments.

Management practices for treating diabetic ketoacidosis (DKA) vary widely among 59 internal medicine departments in Denmark, according to results of a questionnaire-based study in press in an upcoming issue of Diabetes Research and Clinical Practice.

The study identified 24 different insulin regimens and 21 fluid protocols used at the responding departments (Diab. Res. Clin. Pract. 2006 [Epub doi:10.1016/j.diabres.2006.10.013]). “In many cases, the treatment routines employed are not supported by evidence from clinical trials,” wrote lead author Dr. Otto M. Henriksen of the endocrine section at Bispebjerg Hospital, University of Copenhagen, and colleagues.

Overall, 32% of departments managed all patients with DKA in an intensive care unit, whereas 22% used a general medical unit and 32% used an acute medical admission unit.

Most respondents administered an initial regular insulin dose of 10–20 U (median, 16 U) followed by a lower-dose hourly administration of 4–10 U/hour (median, 6 U/hour) of regular insulin. The most common criterion for stopping intensive insulin was resolution of acidosis, used by 76% of departments, followed by the ability to eat and drink (42%), resolution of ketosis (31%), and near-normoglycemia (25%); 53% waited until patients attained at least two of these individual criteria.

Almost all of the respondents used isotonic saline for hydration; 83% administered separate potassium infusions of isotonic potassium-sodium-chloride, and 10% used isotonic potassium chloride.

The recommended fluid administration volumes for the first 8 hours of treatment ranged from 3,750 to 7,700 mL, with a median of 4,800 mL. A mean of 44% of the total volume was derived from potassium supplementation (range, 29%–56%).

More than two-thirds of departments relied on degree of acidosis alone to determine bicarbonate use; 36% used an arterial pH below 7.1 as their threshold to initiate treatment. Another 11% of departments supplemented degree of acidosis with clinical criteria.

In terms of acidosis monitoring, 39% of departments used arterial punctures, 30% used venous blood samples, and 20% used an interchangeable method. Ketosis was most often monitored using a urine dipstick (77%).

Rates of serious complications within the prior 5 years, which were based solely on respondents' recollections, were significantly lower than would be expected from a national registry and included five deaths, four cerebral edemas, and three thromboembolic events.

“The results do suggest that treatment of DKA is perceived as relatively uncomplicated regardless of routine management guidelines,” the researchers concluded. They proposed that national, evidence-based guidelines could reduce durations of hospitalization and increase the cost-effectiveness of DKA treatments.

Management practices for treating diabetic ketoacidosis (DKA) vary widely among 59 internal medicine departments in Denmark, according to results of a questionnaire-based study in press in an upcoming issue of Diabetes Research and Clinical Practice.

The study identified 24 different insulin regimens and 21 fluid protocols used at the responding departments (Diab. Res. Clin. Pract. 2006 [Epub doi:10.1016/j.diabres.2006.10.013]). “In many cases, the treatment routines employed are not supported by evidence from clinical trials,” wrote lead author Dr. Otto M. Henriksen of the endocrine section at Bispebjerg Hospital, University of Copenhagen, and colleagues.

Overall, 32% of departments managed all patients with DKA in an intensive care unit, whereas 22% used a general medical unit and 32% used an acute medical admission unit.

Most respondents administered an initial regular insulin dose of 10–20 U (median, 16 U) followed by a lower-dose hourly administration of 4–10 U/hour (median, 6 U/hour) of regular insulin. The most common criterion for stopping intensive insulin was resolution of acidosis, used by 76% of departments, followed by the ability to eat and drink (42%), resolution of ketosis (31%), and near-normoglycemia (25%); 53% waited until patients attained at least two of these individual criteria.

Almost all of the respondents used isotonic saline for hydration; 83% administered separate potassium infusions of isotonic potassium-sodium-chloride, and 10% used isotonic potassium chloride.

The recommended fluid administration volumes for the first 8 hours of treatment ranged from 3,750 to 7,700 mL, with a median of 4,800 mL. A mean of 44% of the total volume was derived from potassium supplementation (range, 29%–56%).

More than two-thirds of departments relied on degree of acidosis alone to determine bicarbonate use; 36% used an arterial pH below 7.1 as their threshold to initiate treatment. Another 11% of departments supplemented degree of acidosis with clinical criteria.

In terms of acidosis monitoring, 39% of departments used arterial punctures, 30% used venous blood samples, and 20% used an interchangeable method. Ketosis was most often monitored using a urine dipstick (77%).

Rates of serious complications within the prior 5 years, which were based solely on respondents' recollections, were significantly lower than would be expected from a national registry and included five deaths, four cerebral edemas, and three thromboembolic events.

“The results do suggest that treatment of DKA is perceived as relatively uncomplicated regardless of routine management guidelines,” the researchers concluded. They proposed that national, evidence-based guidelines could reduce durations of hospitalization and increase the cost-effectiveness of DKA treatments.