Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
Can J Diabetes. 2022 Apr;46(3):269-276.e2. doi: 10.1016/j.jcjd.2021.10.010. Epub 2021 Nov 6.
Diabetic ketoacidosis (DKA) is a common acute life-threatening complication of poorly controlled diabetes mellitus contributing to considerable mortality and morbidity. Use of standardized treatment protocols improves patient outcomes in the emergency department (ED) for many conditions, but variability in adult DKA treatment protocols has not been assessed across EDs. In this study, we compared DKA treatment protocols from adult EDs across Canada to highlight inconsistencies in recommended DKA management.
ED staff in Canada were solicited for their treatment protocols used to guide acute ED DKA management. Information regarding initial fluid resuscitation and maintenance fluid, potassium replacement, insulin therapy and bicarbonate administration was abstracted from each protocol, collated in a table and compared.
Thirty-six unique protocols were obtained representing 85 institutions (40 urban and 45 rural, with a 65.1% response rate) across Canada, with no protocol use for 4 urban centres. Similarities in protocols included the intravenous insulin infusion rate and instructions for switching to subcutaneous insulin. Variability was noted in the rate, amount and type of fluid bolus given (0.5 to 2 L of normal saline or Ringer's lactate over 15 minutes to 2 hours), the criteria determining the amount, potassium supplementation at normo/hypokalemic ranges, when to add dextrose to maintenance fluid, insulin bolus inclusion and bicarbonate administration.
This is the first comparison of adult DKA treatment protocols in Canada. Although several common approaches were identified, variability was found in initial fluid boluses, initial insulin bolus and role of bicarbonate, necessitating further study to ensure local DKA protocols reflect current evidence-based best practices for optimal patient clinical outcomes.
糖尿病酮症酸中毒（DKA）是一种常见的、由糖尿病控制不良引起的急性致命并发症，导致相当高的死亡率和发病率。在许多情况下，使用标准化的治疗方案可以改善急诊科（ED）患者的预后，但不同 ED 之间成人 DKA 治疗方案的差异尚未得到评估。在这项研究中，我们比较了加拿大各地 ED 成人 DKA 治疗方案，以突出推荐的 DKA 管理方面的不一致性。
我们向加拿大的 ED 工作人员征求了他们用于指导急性 ED DKA 管理的治疗方案。从每个方案中提取了有关初始液体复苏和维持液、钾替代、胰岛素治疗和碳酸氢盐给药的信息，将其整理在一个表格中并进行比较。
我们获得了 36 个独特的方案，代表了加拿大 85 个机构（40 个城市和 45 个农村，应答率为 65.1%），4 个城市中心没有使用任何方案。方案之间的相似之处包括静脉内胰岛素输注率和转换为皮下胰岛素的说明。在给予的液体冲击量、速度和类型（0.5 至 2 L 生理盐水或林格氏乳酸盐，在 15 分钟至 2 小时内）、决定补充量的标准、正常/低钾血症范围的钾补充、何时在维持液中添加葡萄糖、胰岛素冲击量和碳酸氢盐给药方面存在差异。
这是加拿大首次对成人 DKA 治疗方案进行比较。虽然确定了几个常见的方法，但在初始液体冲击、初始胰岛素冲击和碳酸氢盐的作用方面存在差异，需要进一步研究以确保当地的 DKA 方案反映了最佳的患者临床结局的当前循证最佳实践。
