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<< Diabetic Emergencies: Diagnosis And Management Of Hyperglycemic Disorders
Critical Appraisal Of The Literature
Since the literature on diabetic hyperglycemic emergencies is fairly mature, there are a number of review articles that
cover basic management of hyperglycemic emergencies.4 The 2003 American Diabetes Association review presents
that group’s latest consensus recommendations.4 The substance of these recommendations has been covered in
detail in this article.
The state of the literature concerning some key discussions made in this article is summarized as follows.
Use of insulin by intravenous infusion is well-supported by appropriately conducted randomized, controlled trials that have adequate power. Meta-analysis of the data further supports this conclusion. Use of insulin by other routes has supportive evidence from well-conducted studies. These studies are older, but nonetheless valid.
Use of fluid replacement in DKA in both adults and children, use of fluid replacement in HHS in adults, and use of electrolyte replacement in both DKA and HHS in adults and DKA in children, as noted in this text and in the clinical
pathways, are well-supported by well-designed trials that have adequate power. Meta-analysis of the data further supports the conclusions.
Bicarbonate therapy is not well-supported, and there is conflicting evidence in the literature. The weight of the evidence appears to support use of bicarbonate in patients with pH levels less than 7.0, but this recommendation may change with better evidence.
Use of phosphate replacement has shown no evidence of clinical benefit to the vast majority of patients with DKA and is not recommended. Replacement of phosphate may be of some benefit in patients who have cardiac dysfunction or respiratory depression. Replacement of phosphate when phosphate is lower than 1.0 is indicated and is wellsupported by appropriately conducted randomized, controlled trials that have adequate power.
Cerebral edema associated with DKA has only a limited number of studies that present somewhat conflicting results, resulting in different recommendations for therapy. Currently, the strength of evidence cannot conclusively support one recommendation over another. The best advice for the emergency practitioner is to be wary of this condition in all diabetic patients who have an alteration of consciousness and hyperglycemia.
cover basic management of hyperglycemic emergencies.4 The 2003 American Diabetes Association review presents
that group’s latest consensus recommendations.4 The substance of these recommendations has been covered in
detail in this article.
The state of the literature concerning some key discussions made in this article is summarized as follows.
Use of insulin by intravenous infusion is well-supported by appropriately conducted randomized, controlled trials that have adequate power. Meta-analysis of the data further supports this conclusion. Use of insulin by other routes has supportive evidence from well-conducted studies. These studies are older, but nonetheless valid.
Use of fluid replacement in DKA in both adults and children, use of fluid replacement in HHS in adults, and use of electrolyte replacement in both DKA and HHS in adults and DKA in children, as noted in this text and in the clinical
pathways, are well-supported by well-designed trials that have adequate power. Meta-analysis of the data further supports the conclusions.
Bicarbonate therapy is not well-supported, and there is conflicting evidence in the literature. The weight of the evidence appears to support use of bicarbonate in patients with pH levels less than 7.0, but this recommendation may change with better evidence.
Use of phosphate replacement has shown no evidence of clinical benefit to the vast majority of patients with DKA and is not recommended. Replacement of phosphate may be of some benefit in patients who have cardiac dysfunction or respiratory depression. Replacement of phosphate when phosphate is lower than 1.0 is indicated and is wellsupported by appropriately conducted randomized, controlled trials that have adequate power.
Cerebral edema associated with DKA has only a limited number of studies that present somewhat conflicting results, resulting in different recommendations for therapy. Currently, the strength of evidence cannot conclusively support one recommendation over another. The best advice for the emergency practitioner is to be wary of this condition in all diabetic patients who have an alteration of consciousness and hyperglycemia.
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