Over 90,000 U.S. hospital admissions have DKA as a primary diagnosis. Despite published management guidelines, there are significant differences in treatment plan, rate of ICU admissions and length of stay. The use of an early intensivist directed protocol reduces the duration of acidemia and ICU admissions.
Patients admitted into the ED, with a primary diagnosis of DKA during a two month period in 2005 (Intervention) were treated with early intensivist driven protocol utilizing crystalloids and a constant infusion of insulin with IV boluses. Patients were treated with the standard 0.1 units/kg IV bolus and 0.1 unit/kg/hour IV infusion of insulin titrated to the blood glucose. However, in this study, the treatment was complimented with IV boluses of insulin based on blood glucose measurements. Outcomes measured were duration of acidemia, admission to ICU, and length of hospital stay. Controls were retrospectively obtained by reviewing an equal number of randomly selected charts of patients admitted for DKA during the same period in 2004.
Both groups were matched according to their APACHE II scores. The duration of acidemia in the intervention group ranged from 2-13 hours, (mean 5.9) compared to the control group which ranged from 7-19.5 hours (mean 11) p<0.001. Of the intervention group, 10 percent were admitted to the ICU, compared to 30 percent of the control group. The mean length of stay for the intervention group was 4.0 days, compared to 4.5 days for the control group.
In the management of DKA, early intervention by an intensivist directed protocol of crystalloids and insulin with intravenous boluses during and in addition to a constant infusion of insulin, reduces the duration of acidemia, subsequent admissions to the ICU and a trend towards a shorter length of stay.
Involving a critical care team in the management of DKA patients early in their admission to the ER reduces the rate of admissions to the ICU thereby decreasing the total cost of the hospitalization.
Jay Nfonoyim, None.