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

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.