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Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis

Oscar M P Jolobe
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DOI: https://doi.org/10.7861/clinmedicine.18-1-110a
Clin Med February 2018
Oscar M P Jolobe
Manchester Medical Society
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Editor – Notwithstanding the statement made by the authors of this paper that ‘Fluid replacement is the most important initial management [in diabetic ketoacidosis]’,1 the caveat is that intravenous fluid (IVF) replacement is contraindicated when pulmonary oedema is present on admission in a patient with diabetic ketoacidosis (DKA).2,3 In some of these cases, advanced chronic renal failure is an associated feature.2 Pulmonary oedema may also be a feature when non-ketotic hyperglycaemia occurs in a patient with chronic renal failure managed by haemodialysis.4 Both in the context of DKA2 and non-ketotic hyperglycaemia,4 one of the underlying causes of pulmonary oedema is the osmotic shift of fluid from the intracellular to the extracellular fluid compartment as a consequence of severe hyperglycaemia. This may overwhelm the pulmonary circulation when there is impaired excretion of that sudden additional extracellular fluid load. In some of these patients the sole use of insulin to correct hyperglycaemia may be instrumental in the resolution of pulmonary oedema.2,4

Pulmonary oedema may also be present on admission in a DKA patient with coexisting congestive heart failure.3 In that context IVF replacement can be withheld, and DKA can be managed solely with intravenous insulin infusion.3 The associated pulmonary oedema resolves after intravenous administration of frusemide.3 Also in the context of cardiogenic pulmonary oedema a potential alternative treatment strategy is the use of intravenous nitrate infusion,5 the latter a well-tried strategy in the management of pulmonary oedema complicating myocardial infarction.6 The advantage of the latter strategy is that, in a DKA patient concurrently managed with an insulin infusion, hypokalaemia is less likely to be an outcome than might be the case when diuretics are coprescribed with insulin infusion.

  • © Royal College of Physicians 2018. All rights reserved.

References

  1. ↵
    1. Kempegowda P
    , Coombs B, Nightingale P, et al. Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis. Clin Med 2017;17:389–94.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Varma R
    , Karim M. Lesson of the month 1: Diabetic ketoacidosis in established renal failure. Clin Med 2016:16:392–3.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Jolobe O
    . Potassium status should be evaluated also when diabetic ketoacidosis is complicated by heart failure. Am J Emerg Med 2016;29:955.
    OpenUrl
  4. ↵
    1. Kaldany A
    , Curt GA, Estes M, et al. Reversible acute pulmonary edema due to uncontrolled hyperglycamia in diabetic individuals with renal failure. Diabetes Care 1982;5:506–11.
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Jolobe OM
    . Lessons from the EuroHeart survey. Eur Heart J 2007;28;1037–9.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Nelson GIC
    , Silke B, Ahuja RC. Haemodynamic advantages of isosorbide dinitrate over frusemide in acute heart failure following myocardial infarction. Lancet 1983;1:730–2.
    OpenUrlPubMed
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Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis
Oscar M P Jolobe
Clinical Medicine Feb 2018, 18 (1) 110-111; DOI: 10.7861/clinmedicine.18-1-110a

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Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis
Oscar M P Jolobe
Clinical Medicine Feb 2018, 18 (1) 110-111; DOI: 10.7861/clinmedicine.18-1-110a
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