Evolutive physicochemical characterization of diabetic ketoacidosis in adult patients admitted to the intensive care unit ☆ Anselmo Dantas Lopes, Alexandre Toledo Maciel, Marcelo Park ⁎ Intensive Care Unit, Emergency Department, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil Keywords: Metabolic acidosis; Diabetes; Ketoacidosis; Strong ion gap; Intensive care unit Abstract Purpose: The aim of this study was to characterize the first 48-hour evolution of metabolic acidosis of adult patients with diabetic ketoacidosis admitted to the intensive care unit. Materials and Methods: We studied 9 patients retrieved from our prospective collected database, using the physicochemical approach to acid-base disturbances. Results: Mean (SD) age was 34 (13) years; mean (SD) Acute Physiology and Chronic Health Evaluation II score was 16 (10); mean (SD) blood glucose level on admission was 480 (144) mg/dL; mean (SD) pH was 7.17 (0.18); and mean (SD) standard base excess was -16.8 (7.7) mEq/L. On admission, a great part of metabolic acidosis was attributed to unmeasured anions (strong ion gap [SIG], 20 ± 10 mEq/L), with a wide range of strong ion difference (41 ± 10 mEq/L). During the first 48 hours of treatment, 297 ± 180 IU of insulin and 9240 ± 6505 mL of fluids were used. Metabolic improvement was marked by the normalization of pH, partial correction of standard base excess, and a reduction of hyperglycemia. There was a significant improvement of SIG (7.6 ± 6.2 mEq/L) and a worsening of strong ion difference acidosis (36 ± 5 mEq/L) in the first 24 hours, with a trend toward recuperation between 24 and 48 hours (38 ± 6 mEq/L). Conclusion: Initial metabolic acidosis was due to SIG, and the treatment was associated with a significant decrease of SIG with an elevation of serum chloride above the normal range. © 2011 Elsevier Inc. All rights reserved. 1. Introduction Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus that can be life-threatening if not properly treated. It is characterized by the biochemical triad of increased anion gap (AG) metabolic acidosis, uncontrolled hyperglycemia, and increased total body ketone concentra- tion. Except in mild cases, DKA is usually managed in the intensive care unit (ICU), and treatment requires a continuous infusion of intravenous insulin, correction of dehydration and electrolyte imbalance, identification and treatment of precip- itating events, and frequent patient monitoring [1]. During the evolution of the disease, mild to severe metabolic acidosis from several sources is the hallmark of patients with DKA. Guidelines do not provide detailed instructions about the metabolic acidosis evolution in adequately supported and complicated cases or on how to interpret and act upon acid-base abnormalities in this setting ☆ The authors do not have conflicts of interest to declare. ⁎ Corresponding author. E-mail address: mpark@uol.com.br (M. Park). 0883-9441/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2010.08.013 Journal of Critical Care (2011) 26, 303–310