While rapid tube thoracostomy is still preferred in an unstable patient, pigtail catheters with Heimlich valves are increasingly preferred to large bore chest tubes in the treatment of pneumothoraxes and simple pleural effusions due to their less traumatic less painful insertion and lower cost. They also offer decreased risk of haemorrhage in anticoagulated patients or those with bleeding diathesis.
- A VBG is adequate for the diagnosis and ongoing management of patients with DKA. ABGs offer no added benefit and are associated with increased pain and complications.
- Patients with DKA may present with a weak or absent nitroprusside assay reaction on urinalysis for ketones as this test only checks for acetoacetate (the minor ketone body produced in DKA). Serum beta-hydroxybutyrate testing may be helpful in certain cases in making the diagnosis.
- There is no established role for administration of sodium bicarbonate to patients with DKA regardless of their pH. Sodium bicarbonate administration is associated with more complications including hypokalaemia and cerebral oedema.
- Insulin should not be started in patients with DKA until the serum potassium level is confirmed to be > 3.5 mEq/L. The use of an insulin bolus prior to infusion has not been shown to improve any patient centred outcomes or surrogate markers and is associated with an increased rate of hypoglycaemic episodes.