Table 3—

Summary of major recommendations

RecommendationsGrading
• Initiate insulin therapy according to recommendations in position statement.A
• Unless the episode of DKA is mild, regular insulin by continuous intravenous infusion is preferred.B
• Assess need for bicarbonate therapy and, if necessary, follow treatment recommendations in position statement: bicarbonate may be beneficial in patients with a pH <6.9; not necessary if pH is >7.0C
• Studies have failed to show any beneficial effect of phosphate replacement on the clinical outcome in DKA. However, to avoid cardiac and skeletal muscle weakness and respiratory depression due to hypophosphatemia, careful phosphate replacement may sometimes be indicated in patients with cardiac dysfunction, anemia, or respiratory depression and in those with serum phosphate concentration <1.0 mg/dl.A
• Studies of cerebral edema in DKA are limited in number. Therefore, to avoid the occurrence of cerebral edema, follow the recommendations in the position statement regarding a gradual correction of glucose and osmolality as well as the judicious use of isotonic or hypotonic saline, depending on serum sodium and the hemodynamic status of the patient.C
• Initiate fluid replacement therapy based on recommendations in position statement.A
  • Scientific evidence was ranked based on the American Diabetes Association’s grading system. The highest ranking (A) is assigned when there is supportive evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including evidence from a meta-analysis that incorporated quality ratings in the analysis. An intermediate ranking (B) is given to supportive evidence from well-conducted cohort studies, registries, or case-control studies. A lower rank (C) is assigned to evidence from uncontrolled or poorly controlled studies or when there is conflicting evidence with the weight of the evidence supporting the recommendation. Expert consensus (E) is indicated, as appropriate. For a more detailed description of this grading system, refer to Diabetes Care 24 (Suppl. 1): S1–S2, 2001.