Four Articles, Article Review Example

Introduction

The policy/procedure selected for improvement in this literature review pertains to diabetic ketoacidosis. As such, the literature chosen will be related to different management protocols adapted by health care institutions in the management of diabetic ketoacidosis (DKA). This is a life threatening medical condition occurring as a complication of diabetes mellitus.The incidence is highest among patients with type 1 diabetes mellitus(Eledrisi, Alshanti, Shah, Brolosy& Jaha, 2006).

However, there has been reported prevalence among type 2 diabetics when there is infection or persistent uncontrolled blood sugar levels.The etiology for diabetic ketoacidosis is consistent insufficient insulin. Consequently, pathophysiologic changes occur whereby the body resorts to burning fatty acids. In response acidic ketone bodies are produced. When patients arrive at the emergency room they are often dehydrated; labored breathing (Kussmaul’s); thirsty, frequently voiding; nauseated or vomiting; high blood sugar levels (Eledrisi et.al 2006).

Literature Review

Article 1: Klocker, A. Phelan, H. Twigg,S., & Craig, M. (2013).Blood ?-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review.Diabet Med. 30(7); 818-24

The aim of this study was to evaluate the effectiveness of capillary or serum ?-hydroxybutyrate testing in diabetic ketoacidosis prevention and management when compared to urine acetoacetate. Researchers reviewed studies retrieved fromMEDLINE, EMBASE, EBM databases. Targeted outcomes were cited as prevention of diabetic ketoacidosis; the time it took for patients to recovery from the condition, costs pertaining to healthcare and patient/ caregiver satisfaction gained from the intervention. In addition the researchers utilized conference proceedings as well as comments fromexperts after reviewing a reference list(Klocker, Phelan, Twigg & Craig, 2013).

Results revealed thatblood ketone testing was more effective in comparison to urine testing. Importantly, a positive relationship from one study was establishing between blood ketone testing and reduced hospitalization frequency. Also three studies revealed thatthere was a reduction recovery time from diabetic ketoacidosis when blood ketone testing was done. One study proved thatgreater satisfaction was achieved with blood ketone testing and costs with no cost escalation. Consequently, researchers concluded that blood ?-hydroxybutyrate testing was far more effective than urine acetoacetate for better outcomes at emergency departments or even in clinical assessment. It is equally more effectivefor fewer hospitalizations as well as less time to recovery from the complication. Potentially, it has the ability of lowering healthcare costs(Klocker et.al, 2013). This finding is an important evidence based protocol that could be adapted by health care institutions.

Article 2: Kitabchi, A. Guillermo E. Umpierrez, E., & Fisher, J. (2009) Hyperglycemic Crises in Adult Patients with Diabetes.Diabetes Care. 32(7); 1335-1347

The focus of the article is for providing a consensus statement expected to outline precipitating factors of diabetic ketoacidosis making relevant recommendations pertaining to diagnosis, treatment, and prevention of adult patients presenting with the condition in emergency settings and hospitals. This consensus was derived from a previous technical review along with current published peer-reviewed articles from 2001(Kitabchi, Guillermo,Umpierrez & Fisher, 2009).

In relation to treatment analysts suggest that successfully managing diabetic ketoacidosis requires that hyperglicaemia, dehydration, and electrolyte imbalances be addressed immediately upon arrival at the emergency department. Besides, it is essential for health care providers to identify the underlying cause and most importantly, frequent monitoring of vitals and blood glucose levels while at the emergency and even after being transferred to a hospital ward(Kitabchiet.al, 2009).

Management protocol outlined specifies distinct fluid replacement guidelines after complete evaluation of capillary glucose and serum ketones. Thereafter, the protocol states that intravenous fluids incorporate specific amounts of soda bicarbonate; insulin and potassium are administered during the first hour of arriving at the emergency or rescue intervention. The administration of insulin has been signified the mainstay treatment. However, with patient drifting from one extreme to the next efficient monitoring is essential during this period (Kitabchi et.al, 2009).

It was further confirmed that many prospective randomized revealed that a intravenous low-dose regular of insulin infusion is adequate for successful recovery of diabetic keto-acidotic patients. Since Hypoglycemia and hypokalemia are two common complications when health care providers become overzealous in their treatment regime of patients with diabetic ketoacidosis it is important that 1-2 hourly blood glucose monitoring be mandatory so that hypoglycemia can be detected early. Importantly, studies reveal that quite a number of diabeticketoacidotic patientsdevelop hypoglycemia while being treated without showing adrenergic manifestations such as nervousness, sweating, hunger and fatigue(Kitabchi et.al, 2009).

Article 3: Blouin, D. (2012).Too much of a good thing.Canadian Family Physician, 58(1), 55-57

This article confirms adherence to protocols in management of diabetic ketoacidosis. It endorses evidence that standardized treatment protocols applications have significantly improved outcomes and tremendously reduced morbidity. As such, the Canadian Diabetes Association publishesguidelines and treatment algorithms every 5 years pertaining to diabetic ketoacidosis management. Therapies confirm fluid replacement; correcting potassium depletion; metabolic acidosis and managing precipitation conditions since ketone excretion forces the body to excrete sodium, potassium, and ammonium. Often this has been adapted standard for emergency management of diabetic ketoacidosis in many health care organizations across the globe(Blouin, 2012).

This review similar to the one conducted by(Klocker, Phelan, Twigg, & Craig, 2013) and(Kitabchi, Guillermo, Umpierrez, & Fisher, 2009) indicated while insulin is the mainstay initial treatment bolus doses may be unnecessary. As such, this is a protocol change endorsed by theCanadian Diabetes Association. Precisely, bolus insulin becomes unnecessary if the infusion rate is at least 0.1 U/kg/h. Monitoring of serumglucose 1 to 2 hours targeting a decrease of 3 to 4 mmol/L in the first hour was also a valuable endorsement to the management protocol espouse through previous evidence based studies, steep decrease in hyperosmolarity is often linked to a serious predispositionof cerebral edema(Blouin, 2012).

The author of this article, however, was rather vocal regarding treating precipitating factors. Two main one were identified as being crucial. Recent studies proved that some 60% of diabetic ketoacidosis cases emerged from infection. Thirty to fifty percent were due to pneumonia and urinary tract infection. Consequently, missing these features during the assessment as well as under-treatment with insulin can seriously alter patient outcomes. Recommendations are that health care provider pay attention to patient use of drugs inclusive ?-blockers, calcium channel blockers, diuretics, loxapine, phenytoin, steroids, and cocaine, which can initiate ketoacidosis conditions (Blouin, 2012).

Cautioning development of treatment complications was another important management protocol guide advanced by this author. Hypoglycemia; cerebral oedema and respiratory syndrome in adults are complication which ought to be carefully evaluated. In summarizing the author recommends that since incidences of diabetic ketoacidosis is increasingly among type 2 diabetic when patients arrive at the emergency unit of any hospital initial treatment must encompass 1 to 2 Liters of normal saline solution transfused during and over the first hour. Serum potassium reading must to be higher than 3.3 mmol/L for insulin therapy to begin. Bicarbonate treatment must be reserved for patients who have a pH less than 7.0(Blouin, 2012).

Article 4: Rosenbloom, A. (2010). The management of diabetic ketoacidosis in children. Diabetes therapy, 1(2); 103-120

The author’s aim in this article was to offer definitions, risk factors, frequency, diagnostic considerations, pathophysiology and management options for children and adolescents affected with diabetic ketoacidosis (DKA). Ultimately, the expectation is to transmit contemporary evidence related to causes of permanent disability or mortality emerging from DKA complication as well as management. Subsequent studies reveal cerebral edema (CE) occurs frequently among children and adolescent during treatment of diabetic ketoacidosis(DKA)(Rosenbloom, 2010).

Recommendations advanced were that these patients should be managed in pediatric centers equipped with the expertise and experience for efficiently evaluating neurologic status;vital signs, and biochemistry can be monitor avoid complications. In circumstances where there is evidence of cerebral edema development immediately the attending physician should intervene with mannitol or hypertonic saline infusion. Essentially, this infusion must begin 1-2 hoursprior to starting insulin therapy (0.1 U/kg/h).‘An initial bolus of 10–20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%–10% dehydration’ (Rosenbloom, 2010, p 103).Potassium (K) replacement is also crucial and ought to begin as early as possible in appropriate quantities. Bicarbonate administration is in this case is contraindicated (Rosenbloom, 2010).

Conclusion

The following literature review pertained to treatment/management of diabetic ketoacidosis of. In the first study researchers offered two distinct interventions whereas the subsequent reviews confirmed protocols which must be followed to reduce irreversible complications and mortality rates. Children were discovered to be vulnerable subjects of cerebral edema complications, which must be evaluated and addressed immediately upon arriving at an experienced healthcare facility.

References

Blouin, D. (2012). Too much of a good thing.Canadian Family Physician, 58(1), 55-57

Eledrisi, M. Alshanti, M, Shah, M. Brolosy B., & Jaha, N. (2006).Overview of the diagnosis and management of diabetic ketoacidosis”. American Journal of Medical Science, 331 (5); 243–51.

Klocker, A. Phelan, H. Twigg, S., & Craig, M. (2013). Blood ?-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review. Diabet Med. 30(7); 818-24

Kitabchi, A. Guillermo E. Umpierrez, E., & Fisher, J. (2009) Hyperglycemic Crises in Adult Patients with Diabetes.Diabetes Care. 32(7); 1335-1347

Rosenbloom, A. (2010). The management of diabetic ketoacidosis in children. Diabetes therapy, 1(2); 103-120