Long-Acting Insulin on the Road to Recovery With Diabetic Ketoacidosis.

creatic hormone insulin, affects millions of individuals every year. In the United States, 29.1 million people had a diagnosis of diabetes in 2012 (9.3% of the US population). Worldwide, the World Health Organization reported 415 million adults with diabetes.1 As the seventh leading cause of death in the United States, diabetes claimed 69 071 lives in 2012.2 Many complications and comorbid conditions are associated with diabetes including myocardial infarction (1.8 times higher risk), stroke (1.5 times higher risk), and cardiovascular deaths (1.7 times higher risk). In adults, diabetes is the most common cause of nontraumatic lower-limb amputations, kidney failure that results in the need for chronic dialysis or kidney transplant, and vision loss/impairment.3 Diabetic ketoacidosis (DKA) is the most serious acute metabolic complication of diabetes. Hospitalizations for DKA in the United States are on the rise. According to epidemiological studies, DKA increased 35% from 1996 to 2006, with primary diagnoses of DKA totaling 136 500 in 2006. Two-thirds of DKA patients are type 1 diabetics, with the majority either between 18 and 44 years old or more than 65 years old. Although overall mortality is low (< 1%), higher mortality is seen in older adults and those with life-threatening conditions.4,5 In addition, the direct and indirect costs incurred for the acute management of DKA exceed $2 billion annually.6,7 Successful treatment of DKA requires correction of dehydration, hyperglycemia, and electrolyte imbalances. Hyperglycemia during acute illness results from increased hepatic glucose production and impaired glucose use in peripheral tissues. Excess counterregulatory hormones such as glucagon, cortisol, and catecholamines increase lipolysis and protein breakdown, also leading to impaired glucose use by peripheral tissues. Further, hyperglycemia increases inflammatory cytokines and leads to immune system dysfunction. These are just a few of the changes that can eventually lead to increased risk of infection, impaired wound healing, multiple organ failure, prolonged hospital stay, and death.4,8,9 The core treatment of DKA involves the administration of regular insulin via continuous intravenous infusion. This route is preferred because of the short half-life (7 minutes) and easy titration of regular intravenous insulin. Hypoglycemia and hypokalemia are 2 common complications of extreme treatment of DKA with an insulin infusion and thus, the nurses’ role in monitoring blood glucose values, electrolyte levels, and anion gap is critically important. Anion gap calculation can be done quickly by using the following formula: (serum Na+ + serum K+) (serum Cl+ serum CO2). More recently, newer options for the treatment of DKA have been studied to determine their safety and effectiveness. Thus, the PICO (patient/problem, intervention, comparison, outcomes) question of interest for this review was, In patients receiving an intravenous insulin infusion for DKA, will the co-administration of subcutaneous longacting insulin within 2 to 4 hours of starting an insulin infusion improve recovery from DKA and other clinical and financial outcomes?