Introduction
Diabetic ketoacidosis (DKA) is a condition that can appear in patients suffering from diabetes mellitus (both type 1 and type 2) and, in most severe cases, may turn out to be fatal if not addressed in due time. Although this type of a hyperglycaemic crisis is rather infrequent, its incidence has increased recently, which raises concerns about the impact of DKA on patients’ state, associated morbidity, and economic aspects related to its treatment. In order to prevent adverse consequences, it is crucial to develop protocols or guidelines that would allow making the appropriate, timely diagnosis and preventing further development of the disease (Skitch & Valani, 2015).
Established clinical criteria are necessary to ensure patient monitoring as well as controlling insulin therapy, fluid resuscitation, and electrolyte replacement. Furthermore, DKA treatment is fraught with a number of side effects and complications that require effective strategies to be addressed. Since the condition is also associated with a high cost of stay (app. $2.5 billion per year for both direct and indirect expenses), profound research is needed to ensure that proper preventive measures are taken, and the treatment is administered successfully at an early stage (Gosmanov, Gosmanova, & Dillard-Cannon, 2014).
Literature Review
In order to be able to assess the success of DKA protocols implementation in different countries, two articles were chosen for the review, one of which analyzes guidelines from Canadian pediatric emergency departments while the other assesses the effectiveness of protocols developed by the Joint British Diabetes Society (JBDS).
The authors of the first study, Skitch and Valani (2015), review DKA protocols across Canada with the purpose of finding their similarities and differences. They hypothesize that all protocols should be consistent with best practices, non-contradictory, and evidence-based. The researchers used the following methodology: They obtained copies of DKA treatment protocols from pediatric teriary centers across the country and performed a comparative analysis, for which information about the initial amount of fluid bolus, insulin infusion rate, maintenance fluid rate, administration of bicarbonate, potassium replacement, etc. was collected and critically evaluated.
Documents from 13 hospitals were analyzed and compared. As a result, the researchers proved that all the collected guidelines were chiefly similar and consistent in the recommendations provided for the identified interventions, although there were some variations in the volume of initial fluid bolus and maintenance of fluid rates. Thus, it was concluded that Canadian pediatric DKA protocols were non-contradictory and ensured the implementation of best practices. Yet, existing variations indicated that further research is required (Skitch & Valani, 2015).
The major strength of the study is its well-structured design and profound statistical analysis. The researchers clearly indicated the parameters used for the comparison and provided a thorough investigation of all the hospitals included in the sample using the selected framework. The results are presented in tables (demonstrative and precise) and are discussed at length. However, there are also certain weaknesses: The number of units under analysis is rather small, and they are all of the same type, which implies that the situation could be different in other Canadian hospitals. Furthermore, nothing is mentioned about treatment practices (Skitch & Valani, 2015). Thus, it is impossible to estimate whether the described protocols are successfully transferred into practice.
The second study, performed by Crasto, Htike, Turner, and Higgins (2015), investigates the implementation of the guidelines developed by JBDS and hypothesizes that they provide a framework for successful management of DKA in adults in the UK. The method used is a retrospective analysis of 50 cases of DKA. The researchers found out that in 46 percent of patients, who developed DKA, potassium supplementation was not administered (as it should be according to the protocol), and only 10 percent received dextrose. However, no cases of complications or deaths were reported despite the violation of the protocols. The authors concluded that in spite of good adherence to the guidelines at the early stages of treatment, there were still lots of areas of concern, such as inadequate fluid management, metabolic monitoring, and iatrogenic hypoglycemia (Crasto et al., 2015).
Unlike previous research, this study is practice-oriented, which is its major strength. Researchers perform a deep analysis of the implementation of DKA in real clinical settings. They use a large number of variables in order to establish the connection between the patients’ condition and their age, sex, duration of diabetes, number of hospital admissions, and the length of hospital stay (Crasto et al., 2015). This makes the audit more accurate and demonstrative. However, the main weakness is that the authors fail to provide detailed recommendations to improve the adherence to DKA guidelines, although some options are enumerated. Furthermore, they do not discuss any possible flaws in the protocols that may account for the fact that they are not followed in practice.
Conclusion
Since DKA is a complex condition that requires immediate management within the first 24-48 hours of admission, it is essential for health care units to have clear and well-defined protocols to address the problem timely and efficiently. The incidence of DKA is growing worldwide, and its morbidity and mortality rates are high (Gosmanov et al., 2014). The major bulk of research is devoted to the investigation of either theoretical implications of the protocols of treatment or the ability of hospitals to implement them in practice. As a result, researchers fail to provide recommendations on how these protocols must be improved to be able to fit real clinical settings, as well as how hospital units should prepare to ensure that all the measures indicated in the protocols are taken. This could be one of the future directions of research.
References
Crasto, W., Htike, Z. Z., Turner, L., & Higgins, K. (2015). Management of diabetic ketoacidosis following implementation of the JBDS guidelines: Where are we and where should we go? British Journal of Diabetes, 15(1), 11-16.
Gosmanov, A. R., Gosmanova, E. O., & Dillard-Cannon, E. (2014). Management of adult diabetic ketoacidosis. Diabetes, Metabolic Syndrome and Obesity, 7(1), 255-264.
Skitch, S. A., & Valani, R. (2015). Treatment of pediatric diabetic ketoacidosis in Canada: A review of treatment protocols from Canadian pediatric emergency departments. CJEM, 17(06), 656-661.