You are on page 1of 2

BEST AVAILABLE EVIDENCE

Arterial Blood Gas Analysis: Are Its Values Needed for the Management of Diabetic Ketoacidosis?
Allyson Kreshak, MD Esther H. Chen, MD
From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA.

0196-0644/$-see front matter Copyright 2005 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2004.11.005

SEE EDITORIAL, P. 552.


[Ann Emerg Med. 2005;45:550-551.] Diabetic ketoacidosis is one of the most acute life-threatening metabolic complications of diabetes. The American Diabetes Association considers an initial arterial blood gas analysis to be essential in the management of all patients with suspected diabetic ketoacidosis because the severity of acidemia (determined by the pH) is used as 1 of 5 diagnostic criteria to categorize the degree of diabetic ketoacidosis, determine the route of insulin administration, and inuence disposition decisions.1 Included in its recommendations is the use of serial venous blood gas pH sampling as an accurate and reliable indicator of acidemia to monitor clinical improvement. Why, then, cant a venous pH just as accurately determine the initial acid-base status? Associated with its own risks and complications, arterial blood gas sampling is an additional painful percutaneous procedure for patients, and is often difcult to obtain. Furthermore, its values might not even alter patient management. We therefore reviewed the available literature to determine whether arterial blood gas analysis is clinically useful in the emergency management of diabetic ketoacidosis and whether venous sampling is as accurate as arterial sampling in determining acid-base status.

diagnoses (ie, pneumonia with hypoxia, sleep apnea with hypercarbia), altered treatment in 7 (3.5%) patients, and changed disposition in 2 (1%) patients to hospital admission. Of the 7 cases where treatment was changed, 5 cases were based on the pH, resulting in a change in the route of insulin administration. The remaining 2 patients had either a low PO2 (supplemental O2 was applied) or a high PCO2 (bilevel positive airway pressure therapy was started). Emergency physicians made the nal disposition decision without arterial blood gas results in 47 (97.9%) of 48 patients with conrmed diabetic ketoacidosis and did not alter this decision after reviewing the arterial pH results. Venous pH correlated well with arterial pH (r =.951), with typical values only slightly lower by 0.015. The authors concluded that arterial blood gas results rarely inuenced the nal diagnosis, treatment plan, or nal disposition in patients with suspected diabetic ketoacidosis. Although the number of conrmed diabetic ketoacidosis cases was small, the pH was most useful in changing the initial management. The venous pH may serve as an accurate substitute for arterial pH. Gokel et al3 This was a prospective study comparing venous blood gas and arterial blood gas values in patients with uremia, patients with diabetic ketoacidosis, and normal control subjects. Venous and arterial blood gas samples were obtained from 152 patients (100 uremia, 21 diabetic ketoacidosis, 31 normal control subjects). All samples were analyzed for pH and HCO3. On average, venous pH was 0.05 lower than arterial pH. In the small number of patients with diabetic ketoacidosis, the mean arterial pH was 7.15G0.15, whereas the mean venous pH was 7.10G0.15. In patients with uremia, the mean arterial pH was 7.17G0.14, whereas the mean venous pH was 7.13G0.14. In normal control subjects, the mean arterial pH was 7.39G0.02, whereas the mean venous pH was 7.34G0.02. The authors concluded that venous pH correlated well with arterial pH and could be reliably used to evaluate the acid-base status in patients with uremia and diabetic ketoacidosis, even in this small sample. The venous pH was slightly lower (approximately 0.05) than arterial pH. Brandenberg and Dire4 This was a prospective study to determine whether venous blood gas results could accurately replace arterial blood gas
Volume 45, no. 5 : May 2005

SEARCH STRATEGY
An Ovid MEDLINE (1966 to present) search was performed using the key words blood gas or blood gas analysis, or venous blood gas and diabetic ketoacidosis, limit human and English. This search yielded 134 research articles. Bibliographic references found in these articles were also examined to identify pertinent literature. Only original, peerreviewed, prospective research articles were included. Articles pertaining to pediatric patients were excluded. We identied 4 articles that directly addressed our question.

ARTICLE SUMMARIES

Ma et al2 This was a prospective observational study of 200 patients with suspected diabetic ketoacidosis to determine whether arterial blood gas results inuenced management decisions and to compare arterial and venous pH samples. In the study population, arterial blood gas results changed 2 (1%) nal 550 Annals of Emergency Medicine

Kreshak & Chen results in the initial emergency department evaluation of a convenience sample of patients with suspected diabetic ketoacidosis. Forty-four episodes of diabetic ketoacidosis with complete arterial blood gas and venous blood gas data were analyzed. Venous blood gas sampling was performed during line placement, and all samples were taken before treatment. The mean arterial pH was 7.20G0.14 compared to a venous pH of 7.17G0.13, with an average difference of 0.03 (r =0.9689). The authors concluded that venous pH reliably correlated with arterial pH in patients with suspected diabetic ketoacidosis. Hale and Nattrass This was a small prospective study that compared arterial capillary blood gas results with nger capillary blood gas results in patients presenting with diabetic ketoacidosis. Twenty patients with diabetic ketoacidosis had samples analyzed for pH, HCO3, and PCO2 approximately 2 hours after treatment was initiated. The mean arterial pH was 7.07G0.15, compared with the mean capillary pH of 7.04G0.15, with a mean difference of 0.03 (r=0.89). The mean PCO2 and HCO3 values also signicantly correlated between the arterial and capillary samples, although the capillary values were slightly higher than the arterial values. The authors concluded that compared with arterial blood gas samples, capillary blood samples could reliably determine the acid-base status in patients with diabetic ketoacidosis.
5

Arterial Blood Gas Analysis altering management. Although small differences were noted between arterial blood gas and venous blood gas values, they are unlikely to be clinically signicant. Venous pH is as reliable as arterial pH in determining acidemia, so it would be within the standard of care to use venous blood gas sampling in place of arterial blood gas sampling for the emergency management of diabetic ketoacidosis.
Publication dates: Available online March 8, 2005. Reprints not available from the authors. Address for correspondence: Esther H. Chen, MD, Department of Emergency Medicine, Ground Floor, Ravdin Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104-4283; 215-349-8506, fax 215-6623953; E-mail esther.chen@uphs.upenn.edu. REFERENCES
1. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care. 2003;26(Suppl 1): S109-117. 2. Ma OJ, Rush MD, Godfrey MM, et al. Arterial blood gas results rarely inuence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003;10: 836-841. 3. Gokel Y, Paydas S, Koseoglu Z, et al. Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room. Am J Nephrol. 2000;20:319-323. 4. Brandenburg MA, Dire DJ. Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med. 1998;31:459-465. 5. Hale PJ, Nattrass M. A comparison of arterial and non-arterialized capillary blood gases in diabetic ketoacidosis. Diabet Med. 1988;5: 76-78.

THE BOTTOM LINE


A review of the available literature produced one rigorous study that suggests arterial blood gas results rarely inuence the initial treatment and nal disposition decisions in patients with diabetic ketoacidosis. The pH is most clinically useful in

Access to Annals of Emergency Medicine Online is now reserved for ACEP members and print subscribers. Full-text access to Annals of Emergency Medicine Online is now available for ACEP members and all print subscribers. To activate your individual online subscription, please visit Annals of Emergency Medicine Online by pointing your browser to http://www.mosby.com/AnnEmergMed, follow the prompts to activate your online access, and follow the instructions. To activate your account, you will need your ACEP member number or your subscriber account number, which you can nd on your mailing label. If you need further assistance to access the online journal, please contact Periodicals Services at 800-654-2452. Personal subscriptions to Annals of Emergency Medicine Online are for individual use only and may not be transferred. Use of Annals of Emergency Medicine Online is subject to agreement to the terms and conditions as indicated online. Information is also available at ACEPs home page at www.acep.org.

Volume 45, no. 5 : May 2005

Annals of Emergency Medicine 551