Dunn Bryan K, Coore Hunter, Bongu Navneeth, Brewer Kori L, Kumar Deepak, Malur Anagha, Alkhalisy Hassan
Pulmonary and Critical Care Medicine, East Carolina University Brody School of Medicine, Greenville, USA.
Internal Medicine, East Carolina University Brody School of Medicine, Greenville, USA.
Cureus. 2024 Sep 6;16(9):e68785. doi: 10.7759/cureus.68785. eCollection 2024 Sep.
This review discusses the challenges and controversies in the treatment of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Key areas include the selection of intravenous (IV) fluids, insulin therapy, strategies for preventing and monitoring cerebral edema (CE) by managing hyperglycemia overcorrection, electrolyte replacement, timing of nutrition, use of IV sodium bicarbonate, and airway management in critically ill DKA patients. Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution. Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored potassium levels have been achieved and subcutaneous (SQ) insulin is started only after the resolution of metabolic acidosis. In comparison, the British guidelines recommend using SQ insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone. Although rare, rapid overcorrection of hyperglycemia with fluids and insulin can lead to CE, seizures, and death. Clinicians should be aware of risk factors and preventive strategies for CE. DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia and regular monitoring is essential for DKA management. Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay. For impending respiratory failure, Bilevel positive airway pressure is not recommended due to aspiration risks. Instead, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended. The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of CE. However, IV sodium bicarbonate can be considered if the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, pre-and post-intubation, to prevent metabolic acidosis and hemodynamic collapse that occurs from apnea during intubation. Managing DKA and HHS in critically ill patients includes using balanced IV fluid solutions to restore volume status, followed by continuous IV insulin, early use of SQ glargine insulin, electrolyte replacement, and monitoring, CE preventive strategies by avoiding hyperglycemia overcorrection, early nutritional support, and appropriate airway management.
本综述讨论了糖尿病酮症酸中毒（DKA）和高渗高血糖状态（HHS）治疗中的挑战和争议。关键领域包括静脉输液的选择、胰岛素治疗、通过管理高血糖过度纠正来预防和监测脑水肿（CE）的策略、电解质补充、营养时机、静脉注射碳酸氢钠的使用以及重症DKA患者的气道管理。等渗生理盐水仍然是初始液体复苏的标准，尽管平衡溶液已被证明能更快地解决DKA。当前指南建议在恢复液体状态、达到钾水平后，使用持续静脉胰岛素治疗DKA，只有在代谢性酸中毒缓解后才开始皮下（SQ）胰岛素治疗。相比之下，英国指南建议将甘精胰岛素皮下注射与持续常规静脉胰岛素联合使用，与单独使用持续静脉胰岛素相比，这已显示出能更快地解决DKA且住院时间更短。尽管罕见，但液体和胰岛素导致的高血糖快速过度纠正可导致CE、癫痫发作和死亡。临床医生应了解CE的危险因素和预防策略。DKA常涉及多种电解质异常，如低钾血症、低磷血症和低镁血症，定期监测对于DKA管理至关重要。早期开始口服营养已被证明可缩短重症监护病房住院时间和总体住院时间。对于即将发生的呼吸衰竭，由于存在误吸风险，不建议使用双水平气道正压通气。相反，建议进行插管和机械通气，并监测和管理酸碱及液体状态。不鼓励使用碳酸氢钠，因为其可能会加重酮症、低钾血症以及增加CE风险。然而，如果血清pH值低于6.9，或在插管前后血清pH值小于7.2和/或血清碳酸氢盐水平低于10 mEq/L时，可考虑静脉注射碳酸氢钠，以预防插管期间因呼吸暂停导致的代谢性酸中毒和血流动力学崩溃。在重症患者中管理DKA和HHS包括使用平衡的静脉输液溶液来恢复容量状态，随后使用持续静脉胰岛素、早期使用甘精胰岛素皮下注射、电解质补充和监测、通过避免高血糖过度纠正来预防CE的策略、早期营养支持以及适当的气道管理。
