Sodium bicarbonate and intubation in severe diabetic ketoacidosis: are we too quick to dismiss them?
Tóm tắt
Management of diabetic ketoacidosis (DKA) has internationally established guidelines. However, management of severe, refractory DKA with multiple contributors to acidosis, and management of DKA in patients with altered mentation, remain ambiguous. Use of sodium bicarbonate and intubation in DKA are unpopular treatment practices, but warrant consideration in these unique clinical scenarios. This paper describes a 61-year-old Sri Lankan female who presented with severe DKA, seizures and altered level of consciousness. In her case, the acidosis was secondary to DKA, hyperlactatemia, hyperchloraemic acidosis and acute kidney injury (AKI). Intravenous sodium bicarbonate was used in the management of acidosis. She was intubated due to altered level of consciousness with inadequate respiratory drive to compensate for metabolic acidosis. The outcome in her case was favorable. Intravenous sodium bicarbonate in DKA should be considered for patients with severe, refractory acidosis with hemodynamic instability, hyperkalemia and compounding acidosis due to normal anion gap acidosis or AKI. Intubation should be considered for patients with obtunded mentation unable to achieve respiratory compensation and obtunded mentation where reversal of DKA is unlikely to improve consciousness. Both strategies should be personalized with consideration of individual risk vs benefit.
Từ khóa
Tài liệu tham khảo
Dhatariya KK, Vellanki P. Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA). Curr Diab Rep. 2017;17(5):33. https://doi.org/10.1007/s11892-017-0857-4.PMID:28364357;PMCID:PMC5375966.
Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JA, Courtney CH, Hilton L, Dyer PH, Hamersley MS. for the Joint British Diabetes Societies Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabetic Med. 2011;28:508–15. https://doi.org/10.1111/j.1464-5491.2011.03246.x.
Directorate of Non-Communicable Diseases, Ministry of Health Sri Lanka. National Guideline for Management of Diabetes for Secondary and Tertiary Healthcare Level 2021. https://www.ncd.health.gov.lk/images/pdf/circulars/final_dm_DM_for_secondary_and_tertiary__health_care_providers_feb3rd.pdf. Accessed 21 May 2023.
Gabriel Wardi, Sarah Holgren, Arnav Gupta, Julia Sobel, Aaron Birch, Alex Pearce, Atul Malhotra, Christopher Tainter. A REVIEW OF BICARBONATE USE IN COMMON CLINICAL SCENARIOS. The Journal of Emergency Medicine,2023. ISSN 0736–4679. https://doi.org/10.1016/j.jemermed.2023.04.012.https://www.ncbi.nlm.nih.gov/books/NBK560723/.
Diabetic ketoacidosis: management. BMJ Best Practice. https://bestpractice.bmj.com/topics/en-us/162/management-approach. Accessed 21 May 2023.
Jaber S, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicenter, open-label, randomized controlled, phase 3 trial. The Lancet. 2018;V392(i10141):P31-40. https://doi.org/10.1016/S0140-6736(18)31080-8.
Zhang Z, Zhu C, Mo L, Hong Y. Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis. Intensive Care Med. 2018;44(11):1888–95. https://doi.org/10.1007/s00134-018-5379-2. (Epub 2018 Sep 25 PMID: 30255318).
Lo KB, Garvia V, Stempel JM, Ram P, Rangaswami J. Bicarbonate use and mortality outcome among critically ill patients with metabolic acidosis: A meta analysis. Heart Lung. 2020 Mar-Apr;49(2):167–174. doi: https://doi.org/10.1016/j.hrtlng.2019.10.007. Epub 2019 Nov 14. PMID: 31733880.
Lutterman JA, Adriaansen AA, van ’t Laar A. Treatment of severe diabetic ketoacidosis. A comparative study of two methods. Diabetologia. 1979;17(1):17–21. https://doi.org/10.1007/BF01222972. PMID: 38163.
Lever E, Jaspan JB. Sodium bicarbonate therapy in severe diabetic ketoacidosis. Am J Med. 1983;75(2):263–8. https://doi.org/10.1016/0002-9343(83)91203-2. (PMID: 6309004).
Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed). 1984;289(6451):1035–8. https://doi.org/10.1136/bmj.289.6451.1035.PMID:6091840;PMCID:PMC1443021.
Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med. 1986;105(6):836–40. https://doi.org/10.7326/0003-4819-105-6-836. (PMID: 3096181).
Gamba G, Oseguera J, Castrejón M, Gómez-Pérez FJ. Bicarbonate therapy in severe diabetic ketoacidosis. A double blind, randomized, placebo controlled trial. Rev Invest Clin. 1991;43(3):234–8 PMID: 1667955.
Okuda Y, Adrogue HJ, Field JB, Nohara H, Yamashita K. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clin Endocrinol Metab. 1996;81(1):314–20. https://doi.org/10.1210/jcem.81.1.8550770. PMID: 8550770.
Viallon A, Zeni F, Lafond P, Venet C, Tardy B, Page Y, Bertrand JC. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med. 1999;27(12):2690–3. https://doi.org/10.1097/00003246-199912000-00014. (PMID: 10628611).
Robertshaw H. Diabetic ketoacidosis and bicarbonate therapy. Crit Care. 2000;3:4308. https://doi.org/10.1186/ccf-2000-4308.
Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013;47(7–8):970–5. https://doi.org/10.1345/aph.1S014. Epub 2013 PMID: 23737516.
Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Ann Intensive Care. 2011;1(1):23. https://doi.org/10.1186/2110-5820-1-23.PMC3224469.
Ozturk Z, Kilic A, Ozdemir G, Savas Erdeve S, Cetinkaya S. Sodium bicarbonate is safe but not useful in the management of severe diabetic ketoacidosis. Annals of Medical Research. 2023;30(4):474–80 Retrieved from https://www.annalsmedres.org/index.php/aomr/article/view/4408.
Lizzo JM, Goyal A, Gupta V. Adult Diabetic Ketoacidosis. [Updated 2022]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560723/.
Gallo de Moraes A, Surani S. Effects of diabetic ketoacidosis in the respiratory system. World J Diabetes. 2019;10(1):16–22. doi: https://doi.org/10.4239/wjd.v10.i1.16. PMID: 30697367; PMCID: PMC6347653.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347653/.