Diabetic ketoacidosis: Treatment in the intensive care unit or general medical/surgical ward?

Table 1 Clinical trials comparing care in the intensive care unit vs the emergency department or medical ward for patients with diabetic ketoacidosis

Ref.	Country	Patients enrolled	Site of management	Therapy used	Outcome	Length of stay
Dunbar et al[12] Retrospective study (January 1994 - March 1995)	United States	61	15: ICU 46: Regular floor	Not mentioned	Mortality due to sepsis in only 1 patient with initial pH < 7.00	ICU: 2 d Regular floor: Not mentioned
Umpierrez et al[14] Prospective randomized open trial	United States	45	15: ICU 30: ED	ICU: Intravenous insulin drip ED: 15 subcutaneous insulin aspart Q1H ED: 15 subcutaneous insulin aspart Q2H	Hypoglycemic event presented in each group in only 1 patient per group. No complications, no recurrence of ketoacidosis and no mortality	ICU: 4.5 ± 3 d ED with SC Q1H: 3.4 ± 3 d ED with SC Q2H 3.9 ± 3 d
Karoli et al[15] Prospective randomized open trial (January 2009 - June 2010)	India	50	25: ICU 25: ED	ICU: 25 intravenous regular insulin ED: 25 subcutaneous insulin lispro	Hypoglycemic event presented, 2 patients in the ICU group and 1 patient in the ED group. No complications, no recurrence of ketoacidosis and no mortality	ICU: 6.6 ± 1.5 d ED: 6.0 ± 1.2 d
Ersöz et al[16] Prospective randomized open trial	Turkey	20	20: ICU	ICU: 10 intravenous regular insulin ICU: 10 subcutaneous insulin lispro	No need to switch to IV regular insulin, no hypoglycemic events, no complications, no recurrence of ketoacidosis and no mortality	Not mentioned
Umpierrez et al[18] Prospective randomized open trial	United States	20	10: ICU 10: MW	ICU: 20 intravenous regular insulin IMU: 10 subcutaneous insulin lispro Regular floor: 10 subcutaneous insulin lispro	Hypoglycemic event presented in each group in only 1 patient per group, no complications, np recurrence of ketoacidosis and no mortality	IMU and Regular floor: 4 ± 2 d ICU: 4 ± 1 d
Sotiropoulos et al[25] Prospective study (June 2007 - May 31 2008)	Greece	21	21: ED	ED: 21 intravenous regular insulin	Myocardial infarction in only 1 patient - Mortality 4.7%	Not mentioned
Della Manna et al[26] Controlled clinical trial (June 2001 - June 2003)	Brazil	60	3: ICU 57: ED	ICU: 3 intravenous regular insulin ED: 27 intravenous regular insulin ED: 30 subcutaneous insulin lispro	Hypoglycemic event on 10 patients, 6 patients due to regular insulin and 4 due to lispro; no complications, no recurrence of ketoacidosis and no mortality	Not mentioned

IMU: Intermediate care unit; SC: Subcutaneous; Q1H: Every hour; Q2H: Every two hours; ICU: Intensive care unit; ED: Emergency department; MW: Medical ward; DKA: Diabetic ketoacidosis.

Table 2 List of conditions requiring admission of patients with diabetic ketoacidosis in the intensive care unit

Myocardial infarction

Congestive heart failure

Acute renal failure

Acute respiratory failure

Altered mental status

Coma

Shock

Hypothermia

Sepsis

Pancreatitis

Gastrointestinal bleeding

Uncontrolled hypertension

End stage renal disease

Hyperkalemia