ケトアシドーシスにおける水分投与（ドリンク） (DRINK)

アクティブコンパレータ：等張食塩水

薬：Fluid resuscitation with isotonic saline only

Isotonic saline only will be used for fluid resuscitation in the first 48 hours of treatment, according to the protocol of English guidelines:

• During the first hour of treatment:

  • In the event of systolic arterial hypotension (SAP<90mmHg): administration of 500 mL over 15 minutes, renewable once, then administration of 1L over 1 hour.
  • In the absence of systolic arterial hypotension (SAP>90mmHg): administration of 1L over 1 hour.

• Between 60 minutes and 8 hours of treatment :

  • 1L over 2 hours, repeated once, then 1L over 4 hours
  • Adjust fluid resuscitation according to clinical tolerance

• After the first 8 hours:

  • 1L over 4h then 1L over 6h
  • Clinical re-evaluation according to standard of care in participating centers

実験的：乳酸リンガー

薬：Fluid resuscitation with Ringer Lactate

Ringer Lactate only will be used for fluid resuscitation in the first 48 hours of treatment, according to the protocol of English guidelines:

• During the first hour of treatment:

  • In the event of systolic arterial hypotension (SAP<90mmHg): administration of 500 mL over 15 minutes, renewable once, then administration of 1L over 1 hour.
  • In the absence of systolic arterial hypotension (SAP>90mmHg): administration of 1L over 1 hour.

• Between 60 minutes and 8 hours of treatment :

  • 1L over 2 hours, repeated once, then 1L over 4 hours
  • Adjust fluid resuscitation according to clinical tolerance

• After the first 8 hours:

  • 1L over 4h then 1L over 6h
  • Clinical re-evaluation according to standard of care in participating centers

Resolution of diabetic ketoacidosis

Compare fluid resuscitaiton with Ringer Lactate to isotonic saline on the resolution of diabetic ketoacidosis at 24 hours from admission to Intensive Care Unit (ICU) in patients with severe diabetic ketoacidosis.

Resolution of ketoacidosis allowing discharge from ICU, defined as the proportion of patients with the following three criteria at 24 hours from ICU admission :

1. capillary or blood glucose < 11 mmol/L
2. ketonemia < 0.6 mmol/l
3. venous or arterial pH ≥ 7,30 or venous or arterial bicarbonate ≥ 18 mmol/L

Speed of resolution of metabolic disorders

Compare fluid resuscitation with Ringer Lactate and isotonic saline solution on the speed of resolution of metabolic disorders in patients admitted to ICU for severe diabetic ketoacidosis.

Proportion of patients and number of hours ("Resolution free hours") within 48 hours of ICU admission with the following three criteria:

1. capillary or blood glucose < 11 mmol/L
2. ketonemia < 0.6 mmol/l
3. venous or arterial pH ≥ 7,30 or venous or arterial bicarbonate ≥ 18 mmol/L

Time of resolution of metabolic disorders

Compare fluid resuscitation with Ringer Lactate and isotonic saline solution on the speed of resolution of metabolic disorders in patients admitted to ICU for severe diabetic ketoacidosis.

Time (in hours) from ICU admission to obtain one of the following three criteria:

1. capillary or blood glucose < 11 mmol/L
2. ketonemia < 0.6 mmol/l
3. venous or arterial pH ≥ 7,30 or venous or arterial bicarbonate ≥ 18 mmol/L

Assess the metabolic tolerance of Ringer Lactate compared to isotonic saline solution

Assess the metabolic tolerance of Ringer Lactate compared to isotonic saline solution in patients admitted to ICU for severe diabetic ketoacidosis.

Occurrence of serious metabolic disorders during ICU stay, defined as :

1. Kalemia < 3 mmol/L
2. Natremia > 145 mmol/L
3. Chloremia > 110 mmol/L
4. Phosphoremia < 0.70 mmol/L
5. Blood glucose < 3.8 mmol/L (i.e. 0.80 g/L)
6. Persistent ketonemia/ketonuria 24 hours after ICU admission 2. Nature and volume (in liters) of fluid administered before inclusion and during the study period in each group 3. Protocol compliance (expressed as % of volume administered in each group)

Assess the impact of Ringer lactate compared with isotonic saline on renal, neurological and cardiac complications

To assess the impact of Ringer lactate compared with isotonic saline on renal, neurological and cardiac complications during ICU stay and outcomes of patients admitted to ICU for severe diabetic ketoacidosis.

Occurrence of adverse events during ICU stay, defined as :

1. Neurological disorders (Glasgow score)
2. Acute renal failure (KDIGO classification)
3. Cardiac disorders (supraventricular and ventricular rhythm disorders, acute coronary syndrome) 2. ICU and hospital length of stay 3. ICU mortality and Day-28 mortality

Assess the impact of Ringer lactate compared with isotonic saline on cardiac complications

To assess the impact of Ringer lactate compared with isotonic saline on cardiac complications during ICU stay and outcomes of patients admitted to ICU for severe diabetic ketoacidosis.

Occurrence of adverse events during ICU stay, defined as :

• Cardiac disorders (supraventricular and ventricular rhythm disorders, acute coronary syndrome)
• ICU and hospital length of stay
• ICU mortality and Day-28 mortality

Assess the impact of Ringer lactate compared with isotonic saline on renal complications

To assess the impact of Ringer lactate compared with isotonic saline on renal, complications during ICU stay and outcomes of patients admitted to ICU for severe diabetic ketoacidosis.

Measure acute renal failure with KDIGO classification.

The Kidney Disease: Improving Global Outcomes (KDIGO) classification system stratifies acute kidney injury (AKI) into levels of severity, determined by changes in serum creatinine (SCr) / estimated creatinine clearance (eCCl), as well as changes in urine output. The strata of severity of AKI can be reached by meeting the criteria for changes in SCr / eCCl or changes in urine output. There are three levels of severity, with level 1 being the least severe and level 3 the most severe.

No cut-off for the study

Assess the impact of Ringer lactate compared with isotonic saline on neurological complications

To assess the impact of Ringer lactate compared with isotonic saline on neurological complications during ICU stay and outcomes of patients admitted to ICU for severe diabetic ketoacidosis.

Measure Neurological disorders with Glasgow score. The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of patients. The scale rates patients on three aspects of reactivity: eye opening, motor responses and verbal responses. It ranges from 3 (coma) to 15 (no disturbance of consciousness). No cut-off for the study.