Jozwiak Mathieu, Hayes Margaret M, Canet Emmanuel, Lautrette Alexandre, Duroyon Maël-Morvan, Molinari Nicolas, Jung Boris
Service de Médecine Intensive-Réanimation, CHU de Nice Hôpital L'Archet 1, 151 Route Saint Antoine de Ginestière, 06200, Nice, France.
Equipe 2 CARRES, UR2CA - Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France.
Crit Care. 2024 Dec 18;28(1):408. doi: 10.1186/s13054-024-05190-w.
Guidelines for diabetic ketoacidosis (DKA) management are limited, resulting in varied practices. This study assessed Intensive Care Unit (ICU) admission criteria, fluid resuscitation, insulin therapy, and metabolic management in adult patients with DKA.
An international survey of ICU clinicians consisted of 39 items that focused on management of DKA and was endorsed by the European Society of the Intensive Care Medicine. An experienced ICU was defined as a unit admitting > 20 patients with DKA per year.
A total of 522 respondents from 57 different countries participated: 295(57%) worked in Europe, 86(16%) in North America, 25(5%) in South America, 52(10%) in Africa, 52(10%) in Asia and 12(2%) in Oceania. Among respondents, 377(72%) worked in teaching hospitals, 355(68%) in medical-surgical ICUs, and 204(39%) in experienced ICUs. The pH value (< 7.20), arterial or venous bicarbonate concentration (< 15 mmol/L), and the need for continuous intravenous insulin (regardless of the dose) were considered criteria for ICU admission by 362(69%), 240(46%) and 264(51%) respondents, respectively. A protocol for fluid resuscitation was available for 290(63%) respondents, 135(29%) administered isotonic saline only, 173(38%) administered balanced solutions only, and 153(33%) administered both. A protocol for insulin therapy was available for 355(77%) respondents. An initial bolus of intravenous insulin was administered by 228(49%) respondents, 221(48%) used an initial continuous intravenous insulin dose of 0.1 UI/kg/h, 42(9%) used an initial predefined fixed dose, 159(35%) based the initial dose on blood glucose and 39(8%) on blood and/or urine ketones. Fluid choice and modalities of intravenous insulin administration did not differ between experienced and non-experienced ICUs. Intravenous insulin administration was more likely to be initiated upon ICU admission (57%vs.45%, p = 0.04) and less likely after initial fluid resuscitation (27%vs.35%, p = 0.04) in experienced ICUs. Arterial or venous pH was monitored by 408(90%) respondents. Arterial blood gases were favored by 236(52%) respondents and venous blood gases were more likely to be performed in experienced ICUs (30%vs.18%,p < 0.01).
The management of patients with DKA remains heterogeneous worldwide. Future randomized trials are needed, especially regarding fluid resuscitation and insulin therapy. Trial registrationNot applicable.
糖尿病酮症酸中毒（DKA）的管理指南有限，导致实践方法各异。本研究评估了成年DKA患者的重症监护病房（ICU）收治标准、液体复苏、胰岛素治疗及代谢管理情况。
对ICU临床医生进行的一项国际调查包含39个聚焦于DKA管理的项目，并得到了欧洲重症监护医学学会的认可。经验丰富的ICU被定义为每年收治超过20例DKA患者的单位。
来自57个不同国家的522名受访者参与了调查：295名（57%）在欧洲工作，86名（16%）在北美，25名（5%）在南美，52名（10%）在非洲，52名（10%）在亚洲，12名（2%）在大洋洲。在受访者中，377名（72%）在教学医院工作，355名（68%）在内外科ICU工作，204名（39%）在经验丰富的ICU工作。分别有362名（69%）、240名（46%）和264名（51%）受访者将pH值（<7.20）、动脉或静脉碳酸氢盐浓度（<15 mmol/L）以及持续静脉注射胰岛素的需求（无论剂量）视为ICU收治标准。290名（63%）受访者有液体复苏方案，135名（29%）仅给予等渗盐水，173名（38%）仅给予平衡液，153名（33%）两者都用。355名（77%）受访者有胰岛素治疗方案。228名（49%）受访者给予静脉注射胰岛素初始推注量，221名（48%）使用初始静脉持续胰岛素剂量0.1 UI/kg/h，42名（9%）使用初始预定义固定剂量，159名（35%）根据血糖确定初始剂量，39名（8%）根据血和/或尿酮体确定初始剂量。经验丰富和经验不足的ICU在液体选择和静脉胰岛素给药方式上没有差异。在经验丰富的ICU中，静脉胰岛素给药更有可能在ICU收治时开始（57%对45%，p = 0.04），而在初始液体复苏后开始的可能性较小（27%对35%，p = 0.04）。408名（90%）受访者监测动脉或静脉pH值。236名（52%）受访者倾向于动脉血气分析，经验丰富的ICU更有可能进行静脉血气分析（30%对18%，p < 0.01）。
全球范围内DKA患者的管理仍然存在差异。未来需要进行随机试验，特别是在液体复苏和胰岛素治疗方面。试验注册不适用。
