DKA: treatment protocols

Answer

Introduction

Diabetic ketoacidosis (DKA) is an adverse complication of diabetes which occurs when blood acids called ketones are produced in high levels resulting in high morbidity and mortality (Dhatariya and Vellanki, 2017).  The universal treatment or management plan for DKA may be lacking. This essay presents thorough literature review of scholarly articles: one by Dhatariya and Vellanki (2017) and another by Tran et al. (2017). Review is done through summarization of content analysis, synthesis, and evaluation.

Review of Literature

The basis for selection of the above articles is that they focus of DKA management approaches and are most recent in publication. Dhatariya and Vellanki (2017) study was initiated by lack of large-scale studies for defining optimal treatment protocol for DKA and hyperglycemic hyperosmolar state (HHS). Trans et al., (2017) review was initiated by a lack of strong evidence for treatment of DKA due to lack of large-randomized controlled trials. The research gaps that initiated both studies are debatable. On the contrary, optimum and whole-wide treatment approaches had been developed long before the publications of the two articles. In 2010, for instance, the collaboration of 9 reputation health agencies developed management protocol for DKA among adults (Joint British Diabetes Societies Inpatient Care Group, 2010). Management of DKA had also been featured on the WHO’s Global Report on Diabetes of 2016. Furthermore, management protocol for DKA had be handled by other authors earlier (Ford et al., 2013; Gosmanov, Gosmanova & Dillard-Cannon, 2014; Gosmanov, Gosmanova, & Kitabchi, 2015)

Methodological approach on how Dhatariya and Vellanki (2017) searched, sorted, and selected their sources is lacking. However, the authors cited 49 sources. Besides, the review was not guided by research questions and that limitations of the review were not disclosed. On the other hand, the rigor of review conducted by Dhatariya and Vellanki (2017) cannot be established due to missing methodology. Regardless of the high value of the content and findings of the review, it cannot be reliably adopted or implemented in a given healthcare system. Ham-Baloyi and Jordan (2016) stressed that clear and well formulated research questions and explicit systematic review methods are essential in order to identify, choose, and critically appraise relevant information from previously published scholarly articles.

The Tran et al. (2017) provided clear objectives, methods, and results supported by evidence. The review focused on insulin administration, intravenous fluids, potassium, phosphate and bicarbonate replacement, and DKA management protocols. Sources derived from the Ovid Medline database were restricted to publications from 1973 to 2017 and addressing DKA among people aged 19 years and more. Tran and colleagues’ (2017) review findings are more reliable and of high quality than those made by Dhatariya and Vellanki (2017). Tran et al. (2017) satisfied Ham-Baloyi and Jordan’s (2016) recommendations that literature reviews should be directed by well formulated research questions, research objectives and methods.

Fluid replacement is the primary treatment in which 0.9% sodium chloride solution is infused (Dhatariya & Vellanki, 2017; Tran et al., 2017). The rates of fluid replacement are similar 15 to 20mL/kg/h (or 1 to 1.5L) within the first hour in the US and 1L in the first 2 hours in the UK (Dhatariya & Vellanki, 2017). Hydration rate remains a contentious issue across the world (Tran et al., 2017). Phosphate replacement therapy is considered not necessary in both countries but insulin infusion rate is 0.1units/kg/h (Dhatariya & Vellanki, 2017).  Contentious issues requiring further investigations include the necessity and beneficial value of bicarbonate, phosphate and potassium replacement therapy (Dhatariya & Vellanki, 2017; Tran et al., 2017).

Tran et al. (2017) revealed various limitations of their review. They stated that theirs was a narrative review (not systematic), thus, it invited more critical analysis and scrutiny of sources. Majority of sources are current (within five years from publication) but some cited sources going back to1970s and 1980s (Tran et al., 2017). Conversely, Dhatariya and Vellanki (2017) did not reveal limitations of their review. But what stands out is lack of methodological approach, unclear review hypothesis and utilization of relatively outdated publication, with some going back to 1945 (Dhatariya & Vellanki, 2017).

Conclusion

There is a need for more strong and broad original studies to transform treatment and management of DKA. Contentious areas and opinions should be addressed. However, treatment approaches should be adopted where consensus statements exist. Future research should seek determine the necessity or beneficial value of bicarbonate, phosphate and potassium replacement therapy as an effective treatment protocol for DKA. Besides, universal hydration rate should be established.