Management of diabetic keto-acidosis in adult patients admitted to intensive care unit: an ESICM-endorsed international survey

Background : Guidelines for diabetic ketoacidosis (DKA) management are limited, resulting in varied practices. This study assessed Intensive Care Unit (ICU) admission criteria, fluid resuscitation, insulin therapy, and metabolic management in adult patients with DKA.Methods : An international survey of ICU clinicians consisted of 39 items that focused on management of DKA and was endorsed by the European Society of the Intensive Care Medicine. An experienced ICU was defined as a unit admitting > 20 patients with DKA per year.Results : A total of 522 respondents from 57 different countries participated: 295 (57%) worked in Europe, 86 (16%) in North America, 25 (5%) in South America, 52 (10%) in Africa, 52 (10%) in Asia and 12 (2%) in Oceania. Among respondents, 377 (72%) worked in teaching hospitals, 355 (68%) in medical-surgical ICUs, and 204 (39%) in experienced ICUs. The pH value (< 7.20), arterial or venous bicarbonate concentration (< 15 mmol/L), and the need for continuous intravenous insulin (regardless of the dose) were considered criteria for ICU admission by 362 (69%), 240 (46%) and 264 (51%) respondents, respectively. A protocol for fluid resuscitation was available for 290(63%) respondents, 135 (29%) administered isotonic saline only, 173 (38%) administered balanced solutions only, and 153 (33%) administered both. A protocol for insulin therapy was available for 355 (77%) respondents. An initial bolus of intravenous insulin was administered by 228 (49%) respondents, 221 (48%) used an initial continuous intravenous insulin dose of 0.1 UI/kg/h, 42 (9%) used an initial predefined fixed dose, 159 (35%) based the initial dose on blood glucose and 39(8%) on blood and/or urine ketones. Fluid choice and modalities of intravenous insulin administration did not differ between experienced and non-experienced ICUs. Intravenous insulin administration was more likely to be initiated upon ICU admission (57% vs. 45%, p = 0.04) and less likely after initial fluid resuscitation (27% vs. 35%, p = 0.04) in experienced ICUs. Arterial or venous pH was monitored by 408 (90%) respondents. Arterial blood gases were favored by 236 (52%) respondents and venous blood gases were more likely to be performed in experienced ICUs (30% vs. 18%,p < 0.01).Conclusions : The management of patients with DKA remains heterogeneous worldwide. Future randomized trials are needed, especially regarding fluid resuscitation and insulin therapy.