Euglycemic diabetic ketoacidosis:A missed diagnosis

Euglycemic diabetic ketoacidosis(DKA)is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose(less than 11 mmol/L).The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units;it may delay diagnosis and treatment causing worse outcomes.Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus.With the addition of sodium/glucose cotransporter-2 inhibitors in diabetes mellitus management,euglycemic DKA incidence has increased.The other causes of euglycemic DKA include pregnancy,fasting,bariatric surgery,gastroparesis,insulin pump failure,cocaine intoxication,chronic liver disease and glycogen storage disease.The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit,milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio.Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones.The diagnostic workup includes arterial blood gas for metabolic acidosis,serum ketones and exclusion of other causes of high anion gap metabolic acidosis.Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration,electrolytes deficit and insulin replacement.The dextrosecontaining fluids should accompany intravenous insulin to correct metabolic acidosis,ketonemia and to avoid hypoglycemia.

Lessons for intensive care units in COVID-19 pandemic-moving towards sustainability

The Coronavirus disease-2019(COVID-19)pandemic has inundated critical care services globally.The intensive care units(ICUs)and critical care providers have been forefront of this pandemic,evolving continuously from experiences and emerging evidence.In this review,we discuss the key lessons from the ongoing wave of COVID-19 pandemic and preparations for a future surge or second wave.The model of sustainable critical care services should be based on 1)infrastructure development,2)preparation and training of manpower,3)implementing standard of care and infection control,4)sustained supply-chain and finally,and 5)surge planning.

Clinical profile of mechanically ventilated COVID-19 patients:A retrospective observational study from Dubai

Background:We did a retrospective analysis of critical coronavirus disease 2019(COVID-19)patients admitted to our intensive care unit(ICU).The objective was to evaluate the outcome,risk factors and effect of prone position in critically ill patients requiring invasive mechanical ventilation(IMV).Patients and methods:The data were collected regarding demographics,comorbidities,laboratory parameters and treatment.Logistic regression was used for analysis of the association of risk factors to the outcome.Results:From 15 March to 30 May 2020,35(59.3%)out of 59 critical COVID-19 requiring IMV were admitted to a tertiary care hospital in Dubai.The day-28 ICU mortality was 28.8% and 48.6% in patients requiring IMV.Prone position(PP)was used in 17(48.6%)patients for median duration of 19(5-20)hours with significant PaO_(2)/FiO_(2) improvement.Acute kidney injury was common(30.5%),and half of the patients required renal replacement therapy(RRT)with higher mortality(77.8%).Lactate dehydrogenase(LDH)odd ratio(OR)-1.006[95%CI-1.00-1.01],D-dimer(OR-1.003[1.000-1.000]),low total leucocyte count(OR-1.135[1.01-1.28]),and lymphopenia(OR-0.909[0.84-0.98])were independently associated with increased risk of IMV.Conclusions:IMV requirement in patients with COVID-19 is associated with higher mortality.Inflammatory markers like LDH,D-dimer,and lymphopenia can be used to predict the prognosis.The patients with COVID-19 on IMV respond significantly with prone position,and it should be considered early with a longer duration.