A-079 Evaluation of American Diabetes Association diagnostic criteria for diabetic ketoacidosis in emergency room patients using point-of-care ketone measurements

Managing Diabetic Ketoacidosis in Children

Euglycemic diabetic ketoacidosis (DKA) (glucose <250milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period. This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05. We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561mg/dL, P < 0.001) and potassium (4.3 vs 5.3mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3mmol/L) was 27.3 vs 19.1% (P = 0.23). Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.

Disclosure: A. Gandhi: None. R. Jeun: None. S. Khan: None. C. Best: None. V.R. Lavis: None. S. Thosani: None.Objective: Diabetic ketoacidosis (DKA) is a life-threatening emergency resulting in significant morbidity and health care utilization. The most common cause of DKA in the general population is insulin nonadherence, but limited data exists on etiologies for DKA in cancer patients. In this study, we characterize the demographic and clinical characteristics of patients admitted with DKA at a comprehensive cancer center. Methods: This single-center retrospective study evaluated 91 patients with 94 admissions for DKA at our institution between January 2019 and December 2021. Demographic, clinical, and biochemical data were obtained from a review of the electronic medical record. Patient characteristics were summarized using descriptive statistics for continuous variables and categorical variables. Results: Of the retrospective cohort, 21% of patients had underlying type 1 diabetes, 48% had type 2 diabetes, and 31% had no prior history of diabetes. 46% were women with median age of 63 years. Among the 91 patients, gastrointestinal malignancies were the most common, followed by dermatological, hematological, and genitourinary malignancies. 65% of patients had metastatic or Stage IV disease at the time of hyperglycemic emergency. Of the 74 patients with baseline HbA1c levels available prior to admission, 39% had poorly controlled diabetes at baseline with HbA1c >9% (75 mmol/mol). Of patients with underlying type 2 diabetes, 24% developed euglycemic DKA secondary to SGLT2 inhibitor use, while in patients with known type 1 diabetes, lack of adequate insulin therapy remained the most common cause of DKA. In 85% of patients without any underlying history of diabetes, cancer associated drug therapy was the most common cause of hyperglycemic emergency, with immune checkpoint inhibitor(ICIs) therapy as the most frequent causative drug . Discussion/Conclusion In this study of patients admitted to a cancer center, we characterize the most common etiologies for DKA based on patient’s underlying diabetes status. This study emphasizes the need for cautious use of SGLT2 inhibitors in patients with type 2 diabetes and cancer given risk of euglycemic DKA in the setting of poor appetite. While inadequate insulin therapy was the most common cause of DKA in cancer patients with known type 1 diabetes, many of these patients were unfamiliar with how to adjust their insulin with poor oral intake associated with chemotherapy, suggesting an important opportunity for diabetes survival skills education in these patients. ICIs were a significant cause of DKA in patients without prior diabetes history, and most admissions were characterized by moderate to severe DKA on presentation, emphasizing the importance of counseling and screening patients early for this complication.Presentation: Sunday, July 13, 2025

Hyperglycemic Emergencies in Adults

Objective: Using a nationwide claim-based database in Japan, we investigated the reality of diabetic ketoacidosis (DKA) in patients with type 2 diabetes (T2D) treated with sodium-glucose cotransporter 2 (SGLT2) inhibitors. Research Design and Methods: We identified initiators of SGLT2 inhibitors in the claims data from April 2014 to June 2019, and investigated the incidence of DKA in patients with T2D. Moreover, in multivariable-adjusted Cox proportional hazard models, hazard ratio (HR) was calculated using age, sex, body mass index (BMI) and the use of continuous subcutaneous insulin infusion (herein referred to as insulin pumps). Furthermore, regarding DKA events as the objective variable, receiver operating characteristic (ROC) analysis was conducted to calculate a cut-off value for the periods from the initiation of the SGLT2 inhibitors. Results: During the observation period, among 173,025 initiators of SGLT2 inhibitors, patients with a diagnosis of DKA were 1,848 (1.1%), and those requiring inpatient treatment were 247 (0.14%). Factors associated with the diagnosis of DKA were 60- &amp;lt; 70years of age (HR, 1.59), BMI &amp;lt; 25kg/m2 (HR, 1.22) and the use of insulin pumps (HR, 4.61). Moreover, Factors associated with DKA requiring inpatient treatment were 60-70 years of age (HR, 2.64) and BMI &amp;lt; 25kg/m2 (HR, 1.31). As for the DKA events, ROC analysis revealed that the cut-off value was 60 days from the initiation of the SGLT2 inhibitors. Conclusions: This survey revealed that the risk of DKA calculated using real-world database was particularly pronounced among 60- &amp;lt; 70years of age and BMI &amp;lt; 25kg/m2 patients. Furthermore, it became clear that special attention should be paid to the onset of DKA for about 60 days from the initiation of the SGLT2 inhibitors. This information would provide guidance to avoid DKA with SGLT2 inhibitors and optimize the treatment of T2D, especially in Asian descent. Disclosure T. Horii: None. Y. Oikawa: None. T. Higashiyama: None. K. Atsuda: None. A. Shimada: Advisory Panel; Self; Astellas Pharma Inc. Speaker’s Bureau; Self; Eli Lilly Japan K.K., Novo Nordisk Inc., Sanofi-Aventis.

The Case Files

Introduction:Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct relationship between end-tidal carbon dioxide (ETCO2), arterial carbon dioxide (PaCO2), and metabolic acidosis, measuring ETCO2 may serve as a surrogate for ABG in the assessment of possible DKA. The current study focuses on the predictive value of capnography in diagnosing DKA in patients referring to the emergency department (ED) with increased blood sugar levels and probable diagnosis of DKA.Methods:In a cross-sectional prospective descriptive-analytic study carried out in an ED, we studied 181 patients older than 18 years old with blood sugar levels of higher than 250 mg/dl and probable DKA. ABG and capnography were obtained from all patients. To determine predictive value, sensitivity, specificity and cut-off points, we developed receiver operating characteristic curves.Results:Sixty-two of 181 patients suffered from DKA. We observed significant differences between both groups (DKA and non-DKA) regarding age, pH, blood bicarbonate, PaCO2 and ETco2 values (p≤0.001). Finally, capnography values more than 24.5 mmHg could rule out the DKA diagnosis with a sensitivity and specificity of 0.90.Conclusion:Capnography values greater than 24.5 mmHg accurately allow the exclusion of DKA in ED patients suspected of that diagnosis. Capnography levels lower that 24.5 mmHg were unable to differentiate between DKA and other disease entities.

New Point-of-Care test identifies diabetic ketoacidosis in triage

Developments in the management of diabetic ketoacidosis in adults: implications for anaesthetists

“The Proof is in the Pudding”: Do SGLT2 Inhibitors Cause Diabetic Ketoacidosis?

This study characterized incidence, patient profiles, risk factors and outcomes of in-hospital diabetic ketoacidosis (DKA) in patients with COVID-19 compared with influenza and pre-pandemic data. This study consisted of 13 383 hospitalized patients with COVID-19 (March 2020-July 2022), 19 165 hospitalized patients with influenza (January 2018-July 2022) and 35 000 randomly sampled hospitalized pre-pandemic patients (January 2017-December 2019) in Montefiore Health System, Bronx, NY, USA. Primary outcomes were incidence of in-hospital DKA, in-hospital mortality, and insulin use at 3 and 6 months post-infection. Risk factors for developing DKA were identified. The overall incidence of DKA in patients with COVID-19 and influenza, and pre-pandemic were 2.1%, 1.4% and 0.5%, respectively (p < .05 pairwise). Patients with COVID-19 with DKA had worse acute outcomes (p < .05) and higher incidence of new insulin treatment 3 and 6 months post-infection compared with patients with influenza with DKA (p < .05). The incidence of DKA in patients with COVID-19 was highest among patients with type 1 diabetes (12.8%), followed by patients with insulin-dependent type 2 diabetes (T2D; 5.2%), non-insulin dependent T2D (2.3%) and, lastly, patients without T2D (1.3%). Patients with COVID-19 with DKA had worse disease severity and higher mortality [odds ratio = 6.178 (4.428-8.590), p < .0001] compared with those without DKA. Type 1 diabetes, steroid therapy for COVID-19, COVID-19 status, black race and male gender were associated with increased risk of DKA. The incidence of DKA was higher in COVID-19 cohort compared to the influenza and pre-pandemic cohort. Patients with COVID-19 with DKA had worse outcomes compared with those without. Many COVID-19 survivors who developed DKA during hospitalization became insulin dependent. Identification of risk factors for DKA and new insulin-dependency could enable careful monitoring and timely intervention.

Gastroparesis may repeatedly induce diabetic ketoacidosis (DKA), and the differential diagnosis of these diseases is challenging because of similar gastrointestinal symptoms. If DKA is accompanied by gastroparesis, patients present with persistent gastrointestinal symptoms without relief and may even experience recurrent DKA. Misdiagnosis results in poor treatment outcomes and prognosis. We hypothesized that biomarkers or screening tools can be identified by comparing the clinical data between DKA alone and DKA + gastroparesis to facilitate early screening. To achieve early detection and diagnosis of DKA + gastroparesis to enable early treatment aimed at relieving gastrointestinal symptoms and preventing re-induction of DKA. We conducted a case-control study in which 15 patients hospitalized for DKA at the Endocrinology Department of Peking Union Medical College Hospital and diagnosed with DKA and gastroparesis between December 1999 and January 2023 (DKA + gastroparesis group) were included. Then, we selected 60 DKA patients without DKA as a control group (DKA alone group) based on gender, age, disease course, and diabetes subtype in a 1:4 matching ratio. Clinical manifestations and physical and laboratory examination results were statistically compared between the groups. The DKA + gastroparesis group was composed of nine males and six females, with a mean age of 35 ± 11 years, while the DKA alone group included 34 males and 26 females, with a mean age of 34 ± 17 years. In the DKA + gastroparesis group, urine ketone levels normalized, while gastrointestinal symptoms persisted despite treatment, and the tests indicated lower glycosylated hemoglobin levels (HbA1c; 7.07% vs 11.51%, P < 0.01), largest amplitude of glycemic excursions (5.86 vs 17.41, P < 0.01), standard deviation of blood glucose (SDBG; 2.69 vs 5.83, P < 0.01), and coefficient of blood glucose variation (0.31 vs 0.55, P = 0.014) compared with the DKA alone group. Probable gastroparesis was considered at HbA1c < 8.55%. Besides, the patients in the DKA + gastroparesis group had lower body mass index (19.28 kg/m2 vs 23.86 kg/m2, P = 0.02) and higher high density lipoprotein cholesterol level (2.34 mmol/L vs 1.05 mmol/L, P = 0.019) compared to the DKA alone group, but no difference was observed in the remaining lipid profiles between the two groups. Gastroparesis should be considered in DKA patients who fail to have improved gastrointestinal symptoms after ketone elimination and acidosis correction, particularly when the HbA1c level is < 8.55%.

We aimed to study the prevalence of hypophosphatemia and its associated risk factors in Diabetic Ketoacidosis (DKA) patients in the pediatric population. We included 65 subjects aged 7 months to 18 years old who were admitted to Hospital Universiti Sains Malaysia (HUSM) for DKA. Patients' socio-demographic and clinical characteristics, and biochemical examinations from their first admission for DKA were analyzed. The diagnosis of DKA was based on the International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria. Multiple logistic regression models examined associations between different variables and hypophosphatemia. The prevalence of hypophosphatemia in DKA was highest on day 1, at 70.8%, with a mean age of 11 on presentation. Multiple logistic regression analysis showed plasma bicarbonate at day 3 [adjusted odds ratio (OR) 1.2, with a p-value of 0.027] and baseline hemoglobin [adjusted OR 0.62, with p-value 0.009] were significantly associated with hypophosphatemia during DKA. The prevalence of hypophosphatemia in DKA pediatric patients admitted to our center was highest on day 1 of admission. There were many factors associated with hypophosphatemia from simple logistic regression analysis. However, our final model revealed that plasma bicarbonate on day 3 and baseline Hb were the only significant risk factors for hypophosphatemia in DKA patients in the pediatric population.

AimA Quality Improvement Project was conducted to assess if Bedford Hospital NHS Foundation Trust was meeting current Trust guidelines for the diagnosis and management of diabetic ketoacidosis (DKA) in adult patients. Method Retrospective data was collected from adult patients admitted with a diagnosis of DKA from January 2020 to December 2020. Data was collected for five key standards based on Trust guidelines: (1) Correct diagnosis of DKA, (2) Correct prescription of Intravenous (IV) fluids and potassium chloride (KCL) replacement, (3) Switching from Fixed Rate Intravenous Insulin Infusion (FRIII) to Variable Rate Intravenous Insulin Infusion (VRIII) following resolution of DKA, (4) The prescription of long-acting insulin during FRIII/VRIII and (5) Appropriate biochemical monitoring via regular venous blood gases (VBGs). Following data analysis, an intervention phase (with distribution of 'DKA diagnosis and management' posters, DKA teaching sessions and email updates on DKA management for medical doctors) was implemented. The cycle was repeated a further two times, with the most recent cycle based on patients admitted between August to November 2021.ResultsThe first cycle consisted of 25 patients. Results showed a 72% adherence to Standard 1, a 64% adherence to Standard 3 and a 76% adherence to Standard 5. There was a notably low adherence to Trust guidelines for Standards 2 and 5, which were 32% and 12% respectively. After the intervention phases described earlier, results from the final cycle of 20 patients admitted between August to November 2021 showed significant improvement in standards 1,3 and 4 with 90%, 100% and 100% adherence to Trust guidelines respectively. Although there was a slight improvement in biochemical monitoring of patients with regular VBGs (20% adherence in the final cycle versus 12% in the first cycle), the correct prescription of IV fluids and KCL replacement remained low (17% adherence in the final cycle versus 32%).ConclusionAwareness and diagnosis of DKA remains high at Bedford Hospital, however there are issues regarding the ongoing management of DKA patients. In particular, the correct prescription of IV fluids with KCL replacement, and regular biochemical monitoring. There is still a lack of awareness as to the appropriate rate of IV fluid resuscitation, and the correct monitoring and replacement of potassium, as well as pH. Recommended changes to improve DKA management are to expand teaching sessions to include Emergency Department (ED) doctors, as well as ED and medical nursing staff, to improve awareness of the correct management and diagnosis of DKA. Further emphasis will be placed on keeping a paper copy of the Trust Adult DKA management protocol in the patients’ notes.Presentation: No date and time listed

Background and purposeIn cinical, some acute pancreatitis patients with diabetes may have diabetic ketoacidosis (DKA). However, the risk factors for DKA in these patients remain unclear. The purpose of this study is to analyze the risk factors for DKA in acute pancreatitis patients with type 2 diabetes.Patients and methodsTwenty-five patients were included in this prospective single-centre study to analyze the incidence and risk factors for DKA in acute pancreatitis patients with type 2 diabetes.ResultsSeven of the twenty-five patients (28%) developed DKA within 48 h of admission. According to whether they had DKA, the twenty-five AP patients were divided into DKA group and non-DKA group. There were significant differences in age (P = 0.014), BMI (P = 0.034), poor previous blood glucose control (P < 0.001) and uric acid concentration (P = 0.041), but no statistically significant differences in sex (P = 0.597), number of drinkers (P = 0.407), number of smokers (P = 1.000), triglyceride level (P = 0.389) and total cholesterol concentration (P = 0.534) between the two groups. In both groups, 1 patients had severe pancreatitis, and the difference was no statistically significant (P = 0.490).ConclusionsThe incidence of DKA in AP patients with diabetes is high. Age, BMI, worse glycemic control and uric acid concentration may be predictors of DKA in AP patients with diabetes.