Correspondence |
Recent advances in the monitoring and management of diabetic ketoacidosis
Retired geriatrician Didsbury Manchester email: oscar.j.lobe{at}yahoo.co.uk
Sir,
Given the fact that diabetic ketoacidosis (DKA) can co-exist with acute left ventricular failure (LVF) when the latter complicates acute myocardial infarction, itself an acknowledged precipitating factor for DKA,1 this is an association that deserved mention and discussion in the above review, especially in view of the problems it poses for clinicians who have to decide between the competing needs of the two disorders.
On the one hand, intravenous fluid (IVF) replacement is integral to the management of the dehydrated patient with DKA, but logic dictates that this is contraindicated in the presence of the coexistence of DKA with LVF.2 The latter line of reasoning is not well articulated by others, hence the recommendation that, even in this context, IVF should still be administered albeit at much slower than usual rates.3 Surely, one of the justifications for routine chest radiography, in addition to electrocardiography and cardiac enzymes in DKA, is to diagnose LVF which might be complicating silent myocardial infarction, because chest radiography is a highly specific modality, with high positive predictive value for the diagnosis of LVF.4 On the basis of their experience which must have included patients with the association of DKA, LVF, and myocardial infarction, the authors should be in a position to advise whether: (a) IV fluids should still be integral to the management of DKA, even when it coexists with radiographically validated LVF, and even LVF-related pulmonary oedema; (b) IV fluids should be withheld but no diuretics given, even in the event of LVF-related pulmonary oedema; (c) whether, especially in the event of LVF-related pulmonary oedema, the twin strategy should be to withhold IV fluids and to administer IV diuretics judiciously; (d) the final option, typically exercised by harassed juniors, is to co-administer IV fluids with bolus IV diuretics, but this seems inherently self contradictory.
In the context of (b) and (c), the question arises as to whether, in the non-dehydrated patient in whom there has not been a significant degree of antecedent osmotic diuresis, potassium deficits are likely to be sufficiently severe as to require replacement by the intravenous route when the continuous insulin infusion gets under way. My guess is that the potassium deficit is not likely to be profound, and that replacement by the oral route will suffice.5
References
1. Wallace TM, Matthews DR. Recent advances in the monitoring and management of diabetic ketoacidosis. Q J Med 2004; 97:773–80.
2. Jolobe OMP. Persisting mortality in diabetic ketoacidosis (letter). Diabetic Medicine 1993; 10:782.
3. Basu A, Close CF, Jenkins D, Kreutz AJ, et al. Persisting mortality in diabetic ketoacidosis. Diabetic Medicine 1993; 10:282–4.
4. Knudsen C, Omland T, Clopton P, et al. Diagnostic value of B-Type Natriuretic Peptide and Chest Radiographic Findings in Patients with Acute Dyspnoea. American Journal of Medicine 2004; 116:363–8.[CrossRef][Web of Science][Medline]
5. Jolobe OMP. Management of hyperglycaemic emergencies (letter). Proceedings of the Royal College of Physicians of Edinburgh 1995; 5:338–9.
Response
Sir,We agree that fluid therapy can be a difficult issue in ketoacidosis, but dehydration is the usual problem, and death can result from failure to treat this adequately. Of course, over-replacement may precipitate cardiac failure. We hope we made this clear in stating that: ‘the need for central venous monitoring should be assessed on an individual basis, but may be required in elderly patients or those with pre-existing cardiac failure.’ Central venous pressure (CVP) monitoring is required if patient has significant cardiac disease.1
This advice is in line with recommendations from the European Diabetes Policy Group (1998), who advise monitoring CVP if cardiac disease is present and advocate more cautious fluid replacement in the elderly.2 And the 2004 ADA position statement suggests: ‘in patients with renal or cardiac compromise, frequent assessment of cardiac, renal and mental status must be performed during fluid resuscitation to avoid iatrogenic fluid overload’.3
With regard to potassium replacement, it is well known that plasma potassium concentrations are a poor guide to total body potassium and that plasma potassium will fall with insulin therapy.4
Oxford Centre for Diabetes, Endocrinology and Metabolism
References
1. English P, Williams G. Hyperglycaemic crises and lactic acidosis in diabetes mellitus. Postgrad Med J 2004; 80:253–61.
2. A desktop guide to Type 1 (insulin-dependent) diabetes mellitus. European Diabetes Policy Group 1998. Diabet Med 1999; 16:253–66.[CrossRef][Medline]
3. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabetes Care 2004; 27(Suppl. 1):S94–102.
4. Chiasson JL, Aris-Jilwan N, Belanger R, et al. Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state. CMAJ 2003; 168:859–66.
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