Diabetic Ketoacidosis In Adults Research Articles

Beta-Hydroxybutyrate Levels and Risk of Diabetic Ketoacidosis in Adults with Type 1 Diabetes Treated with Sotagliflozin.

Introduction: Sodium glucose cotransporter inhibitors may increase beta-hydroxybutyrate (BHB) in insulin-requiring patients. We determined factors associated with BHB changes from baseline (ΔBHB) and diabetic ketoacidosis (DKA) in patients with type 1 diabetes (T1D) receiving sotagliflozin as an insulin adjunct. Research Design and Methods: This post hoc analysis compared ΔBHB levels in adults with T1D receiving sotagliflozin 400 mg or placebo for 6 months. We evaluated clinical and metabolic factors associated with ΔBHB and used logistic regression models to determine predictors associated with BHB values >0.6 and >1.5 mmol/L (inTandem3 population; N = 1402) or with DKA events in a pooled analysis (inTandem1-3; N = 2453). Results: From baseline (median, 0.13 mmol/L), median fasting BHB increased by 0.04 mmol/L (95% confidence interval, 0.03-0.05; P < 0.001) at 24 weeks with sotagliflozin versus placebo; 67% of patients had no or minimal changes in BHB over time. Factors associated with on-treatment BHB >0.6 or >1.5 mmol/L included baseline BHB and sotagliflozin use. Age, insulin pump use, sotagliflozin use, baseline BHB, and ΔBHB were significantly associated with DKA episodes. Independent of treatment, DKA risk increased by 18% with each 0.1-mmol/L increase in baseline BHB and by 8% with each 0.1-mmol/L increase from baseline. Conclusion: Incremental increases in baseline BHB and ΔBHB were associated with a higher DKA risk independent of treatment. Adding sotagliflozin to insulin increased median BHB over 24 weeks in patients with T1D and was associated with increased DKA events. These results highlight the importance of BHB testing and monitoring and individualizing patient education on DKA risk, mitigation, identification, and treatment.

IDF23-0052 Clinical Parameters of Adult Diabetic Ketoacidosis Pre-COVID-19 and during-COVID-19 at a Tertiary Hospital in Kenya

IDF23-0052 Clinical Parameters of Adult Diabetic Ketoacidosis Pre-COVID-19 and during-COVID-19 at a Tertiary Hospital in Kenya

THU293 Enhancement Of Best Practices In Diabetic Ketoacidosis Management Using Standardized Order-sets vs Individual Practitioner Orders

Abstract Disclosure: C. Yim: None. Q. Li: None. T.G. Arnason: None. Diabetic ketoacidosis (DKA) is a hyperglycemic emergency occurring in diabetics due to insulin deficiency. This results in urinary losses of water and electrolytes (sodium, potassium, chloride) and ultimately extracellular fluid volume depletion. Hallmark features of DKA include ketoacidosis, arterial pH &amp;lt; 7.3, bicarbonate &amp;lt;15 mmol/L and an anion gap of &amp;gt;12 mmol/L. The 2018 Diabetes Canada (DC) guidelines outline the key steps of DKA management including fluid resuscitation, resolution of ketoacidosis, correction of electrolytes and management of precipitating factors. Its detailed algorithm identifies three pillars to DKA treatment: IV fluids, serum potassium and acidosis. A 2016 DKA outcome audit at the Royal University Hospital (RUH) in Saskatoon identified that practitioners diverged considerably from (2013) Canadian Diabetes Association guidelines. Subsequently, two standardized preprinted DKA order sets were developed incorporating the 2018 DC recommendations for i) INITIAL and ii) MAINTENANCE DKA management. Their rollout overlapped with annual academic half day sessions on DKA management for postgraduate year 1 residents in internal medicine. These order-sets were initially implemented at RUH in November 2018 and subsequently adopted by some practitioners at St. Paul’s Hospital (SPH). To ensure the order-sets were promoting improved outcomes and adhering to best practices, a retrospective chart review was conducted of all adult DKA admissions at RUH and SPH from Nov. 13, 2018 to December 31, 2020. In total, 279 hospital admissions were reviewed: 99 used practitioners’ own orders, 115 used both initial and maintenance order-sets, 26 used only the initial order-set and 38 used only the maintenance order-set. Use of the INITIAL order set significantly improved compliance (p &amp;lt; 0.0001) with DC 2018 guidelines for recommended insulin dose and timing, fluid resuscitation as well as potassium, sodium and dextrose replacement. Use of the MAINTENANCE order set consistently enhanced outcomes for intravenous fluid selection, subcutaneous insulin overlap, and ensuring a closed anion gap at transition (p &amp;lt; 0.0001). Additionally, the chart review revealed that there were hospital differences for uptake of order sets and compliance to DC 2018 guidelines. There was a significant uptake of order sets at RUH versus SPH (p &amp;lt; 0.0001). RUH consistently met outcomes for appropriate insulin dosing, potassium and dextrose replacement (p &amp;lt; 0.0001). RUH also consistently overlapped IV and SC insulin and ensured a closed insulin gap. The anion gap remained consistently closed post-transition at RUH versus SPH (p = 0.035). These results suggest that utilization of a DKA order set does significantly promote adherence to key best practices outlined in the DC 2018 guidelines. Presentation: Thursday, June 15, 2023

Differential evolution of diabetic ketoacidosis in adults with pre-existent versus newly diagnosed type 1 and type 2 diabetes mellitus

BackgroundDiabetic ketoacidosis (DKA) was once known to be specific to type-1 diabetes-mellitus (T1D); however, many cases are now seen in patients with type-2 diabetes-mellitus (T2D). Little is known about how this etiology shift affects DKA's outcomes.MethodsWe studied consecutive index DKA admissions from January 2015 to March 2021. Descriptive analyses were performed based on pre-existing T1D and T2D (PT1D and PT2D, respectively) and newly diagnosed T1D and T2D (NT1D and NT2D, respectively).ResultsOf the 922 patients, 480 (52%) had T1D, of which 69% had PT1D and 31% NT1D, whereas 442 (48%) had T2D, of which 60% had PT2D and 40% NT2D. The mean age was highest in PT2D (47.6 ± 13.1 years) and lowest in PT1D (27.3 ± 0.5 years) (P < 0.001). Patients in all groups were predominantly male except in the PT1D group (55% females) (P < 0.001). Most patients were Arabic (76% in PT1D, 51.4% in NT1D, 46.6% in PT2D) except for NT2D, which mainly comprised Asians (53%) (P < 0.001). Patients with NT2D had the longest hospital length of stay (LOS) (6.8 ± 11.3 days) (P < 0.001), longest DKA duration (26.6 ± 21.1 h) (P < 0.001), and more intensive-care unit (ICU) admissions (31.2%) (P < 0.001). Patients with PT1D had the shortest LOS (2.5 ± 3.5 days) (P < 0.001), DKA duration (18.9 ± 4.2 h) (P < 0.001), and lowest ICU admissions (16.6%) (P < 0.001).Conclusions/interpretationWe presented the largest regional data on differences in DKA based on the type and duration of diabetes- mellitus (DM), showing that T2D is becoming an increasing cause of DKA, with worse clinical outcomes (especially newly diagnosed T2D) compared to T1D.

Diabetic Ketoacidosis Complications and Management in Pediatrics: A Narrative Review

Diabetic ketoacidosis (DKA) is an endocrine emergency that affects both newly diagnosed and long-term type I diabetic patients as a result of decreasing insulin levels in the blood, insulin resistance, and elevated levels of counter-regulatory hormones. A common and deadly acute consequence in kids with diabetes mellitus is diabetic ketoacidosis. When type I diabetes is newly diagnosed, it can be accompanied by diabetic ketoacidosis. It can also happen when type I diabetes is already present, such as when the demands of an acute illness are more than usual or when insulin administration is decreased as a result of missed doses or insulin pump failure. Furthermore, there are more reports of diabetic ketoacidosis events in kids with type II diabetes mellitus. Although the diagnosis is typically simple in a patient with established diabetes and the anticipated symptoms, a sizable portion of patients with new-onset diabetes initially present with diabetic ketoacidosis. Children with diabetic ketoacidosis are typically treated in an emergency room for the first time. The differential diagnosis of pediatric metabolic acidosis must take diabetic ketoacidosis into account as a significant factor. The pathogenesis, therapy, and probable consequences of this illness will be explained to emergency medicine doctors in this review) Heddy, 2021). The management of pediatric patients draws attention to the uncommon but fatal occurrence of cerebral edema and the excessive use of fluid boluses that may or may not be related to it. Guidelines for managing DKA in adults should not be applied to children and adolescents. The diagnosis of DKA is based on clinical suspicion and subsequent laboratory confirmation: Hyperglycemia (sugar level greater than 11 mmol/L): diabetes warning sign. pH 7.3 and 15 mmol/L of bicarbonate indicate metabolic acidosis. Ketosis, which may include ketonuria or ketonaemia. The severity of DKA depends on the acidity level: Mild: pH 7.3 and/or 15 mmol/L of bicarbonate; Moderate: pH 7.2 and/or 10 mmol/L of bicarbonate. Ketoacidosis associated with diabetes (DKA) Extremely severe: pH 7.1 and/or 5 mmol/L of bicarbonate. DKA can have various deadly consequences. Acute hypoglycemia (during treatment or as a result of utilizing an excessive amount of insulin pump) Cerebral edema, Acute hypokalemia, Acute hypoglycemia, Spontaneous pneumonia. A, B, and C for initial CPR If at all possible, weigh the patient and then use that weight in all calculations. Use an estimated weight from a centile chart or a weight from a recent medical visit as an alternative. Make sure the airway is open. Insert an airway if a child is unconscious (Glasgow Coma Scale Score of 8). In the event that the patient is vomiting or has a reduced level of awareness, insert NGT, aspirate, and place on free drainage. B. An oxygen-only face mask. Draw blood when an IV cannula is in place. Only if the patient is shocked (poor peripheral pulses, poor capillary filling with tachycardia, and/or hypotension) should you provide a bolus of 10 ml/kg 0.9% sodium chloride. Repeat the fluid bolus only after contacting a doctor or pediatric endocrinologist if shock symptoms continue.

1014-P: Evaluation of Diabetic Ketoacidosis Management with a Subcutaneous Insulin Lispro PowerPlan

Diabetic ketoacidosis (DKA) has traditionally been treated with a continuous intravenous insulin infusion, often requiring management in an intensive care unit (ICU) or step-down unit. There has been growing evidence supporting the use of subcutaneous rapid-acting insulin analogs to treat mild-to-moderate DKA (alert patient able to tolerate oral fluid intake, pH &amp;gt;7.0, bicarbonate ≥10), helping to decrease costs and ICU-bed utilization. We sought to establish the efficacy and safety of a subcutaneous insulin lispro protocol developed at UPMC for the treatment of mild-to-moderate DKA. A retrospective chart review was performed on patients across 15 institutions in the UPMC network from February-October 2022 who had the adult DKA PowerPlan subcutaneous insulin lispro subphase ordered. Of 111 cases analyzed, 47 cases were included that properly used the PowerPlan to treat mild-to-moderate DKA. DKA resolution using the PowerPlan was reached in 45/47 (95.7%) cases. The two unsuccessful cases involved delayed recognition of DKA in the emergency department and premature transition to a prandial insulin regimen before DKA resolution. Hypoglycemia (defined as glucose &amp;lt;70) occurred in 9/47 (19.1%) encounters. Only 1/47 (2.1%) encounters involved hypoglycemia directly attributable to the subcutaneous insulin lispro PowerPlan. The remaining cases of hypoglycemia were attributed to not reducing insulin doses when glucoses were &amp;lt;250, giving insulin doses sooner than 2 hours before the prior dose, not starting dextrose-containing fluids when glucoses were &amp;lt;250, and higher co-administered basal insulin doses (&amp;gt;0.3 units/kg). Overall, these results suggest that a subcutaneous insulin analog can be safely and effectively used to treat mild-to-moderate DKA in non-ICU settings. Disclosure J.Quaytman: None. E.Karslioglu-french: Research Support; Abbott. A.Donihi: None.

Exploring ChatGPT's Potential in Facilitating Adaptation of Clinical Guidelines: A Case Study of Diabetic Ketoacidosis Guidelines.

Background This study aimed to evaluate the efficacy of ChatGPT, an advanced natural language processing model, in adapting and synthesizing clinical guidelines for diabetic ketoacidosis (DKA) by comparing and contrasting different guideline sources. Methodology We employed a comprehensive comparison approach and examined three reputable guideline sources: Diabetes Canada Clinical Practice Guidelines Expert Committee (2018), Emergency Management of Hyperglycaemia in Primary Care, and Joint British Diabetes Societies (JBDS) 02 The Management of Diabetic Ketoacidosis in Adults. Data extraction focused on diagnostic criteria, risk factors, signs and symptoms, investigations, and treatment recommendations. We compared the synthesized guidelines generated by ChatGPT and identified any misreporting or non-reporting errors. Results ChatGPT was capable of generating a comprehensive table comparing the guidelines. However, multiple recurrent errors, including misreporting and non-reporting errors, were identified, rendering the results unreliable. Additionally, inconsistencies were observed in the repeated reporting of data. The study highlights the limitations of using ChatGPT for the adaptation of clinical guidelines without expert human intervention. Conclusions Although ChatGPT demonstrates the potential for the synthesis of clinical guidelines, the presence of multiple recurrent errors and inconsistencies underscores the need for expert human intervention and validation. Future research should focus on improving the accuracy and reliability of ChatGPT, as well as exploring its potential applications in other areas of clinical practice and guideline development.

Diabetes Ketoacidosis Is a Cause of Concern in Sodium-Glucose Co-Transporter-2 Inhibitors Medication

Abstract: Diabetic ketoacidosis (DKA) is a dangerous complication that can afflict persons with Type 1 and Type 2 diabetes and is caused by a lack of glucose utilization and insulin generation. DKA is diagnosed by observing the anion gap values, blood glucose level, pH, serum bicarbonate level, and so on. DKA is associated with an elevated blood glucose of &gt; 250 mg/dl (16.7 mmol/l) and is diagnosed by observing the values of anion gap, blood glucose level, pH, serum bicarbonate level, and so on. It occurs more frequently in type 1 diabetics with low insulin levels. Sodium-glucose Co-transporter-2 (SGLT-2) inhibitors are a novel family of anti-diabetic medications that lower blood glucose levels and produce glucosuria. The US Food and Drug Administration (USFDA) has issued a drug safety warning about the increased risk of DKA when using SGLT-2 inhibitors. Following the USFDA's warning, the European Medicine Agency reported 101 more cases of ketoacidosis caused by SGLT-2 inhibitors in people with Type 2 Diabetes Mellitus (EMA). According to the American Association of Clinical Endocrinologists, all SGLT-2 inhibitors should be stopped 3-4 days before major surgery and 24 hours before elective surgery. This review article focuses on the metabolism of ketone bodies and many pathophysiologic mechanisms of SGLT-2 inhibitors, which lower insulin/glucagon ratios, promote glucagon secretion from alpha cells, and increase ketones levels by stimulating lipolysis and resulting in ketogenesis. The primary goal of this study is to improve our understanding of a significant consequence of DKA caused by sodium-glucose cotransporter-2 inhibitors in patients with Type 1 and Type 2 diabetes. Psychosocial factors linked to diabetic ketoacidosis in adults with type 1 diabetes, as well as the prevalence of DKA in COVID-19 patients, have been linked to higher severity of mortality and duration of stay in these patients, according to recent research.

287: ASSOCIATION BETWEEN AN EMERGENCY CRITICAL CARE PROGRAM AND DKA CRITICAL CARE UTILIZATION IN THE ED

Introduction: The Stanford Emergency Critical Care Program (ECCP), in which a dual-boarded EM/CCM physician serves as an embedded consultant during hours of peak ED census, was initiated in 2017. We investigated the association between the ECCP intervention and critical care utilization in ED patients with Diabetic Ketoacidosis (DKA). Methods: This is a retrospective cohort analysis of adult DKA patients in the ED who were admitted to critical care between 2017-2019. Duration of critical care and ICU bed utilization by patients admitted during ECCP hours were compared to patients admitted during non-ECCP hours. Stata was used for all analyses. Results: Of 71 patients identified, 16 (23%) were in the ECCP cohort, and 55 (77%) were admitted outside ECCP hours. No demographic or baseline clinical differences were noted between groups, although ECCP patients had significantly lower initial glucose (419 vs 602, p=0.014). On univariable analysis, there was no significant difference in mortality or length of hospital stay. In terms of critical care utilization, however, ECCP patients were more likely to be downgraded to non-ICU level of care directly from the ED (93.8% vs 45.5%, p=0.001), and also specifically to be downgraded within 6 hours (62.5% vs 12.7%, p< 0.0001). Finally, total critical care duration was reduced during ECCP hours (5.4h vs 14.4h, p=0.0001). These findings remained significant upon multivariable analyses controlling for demographics and baseline clinical characteristics. Conclusions: DKA patients admitted to the ICU during ECCP hours were found to have decreased critical care duration and increased likelihood of downgrade to non-ICU level of care while still in the ED. These results suggest that early care by an embedded intensivist is associated with decreased critical care utilization among DKA patients in the ED. Future research should focus on prospective validation of these findings in a larger cohort, and identifying specific aspects of ECCP care that could be adapted for general ED use.

ODP628 Quality Improvement Project (QIP) On Management Of Diabetic Ketoacidosis (DKA) In Adults In A District General Hospital.

Abstract Aim A 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. Results The 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%). Conclusion Awareness 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

Clinical and biochemical characteristics of diabetic ketoacidosis in adults with type 1 or type 2 diabetes at a tertiary hospital in the United Arab Emirates.

Diabetes ketoacidosis (DKA) is a well-known acute complication of diabetes. This study aims to describe the sociodemographic, clinical, and biochemical characteristics of adult patients with different diabetes types and DKA severities attending a tertiary hospital in the UAE. We retrospectively extracted sociodemographic, clinical, and laboratory data from the electronic medical records of 220 adult patients with DKA admitted to Tawam Hospital between January 2017 and October 2020.Results: The average age was 30.6 ± 16.6 years of whom 54.5% were women, 77.7% were UAE nationals and 77.9% were Type 1 diabetes (T1DM). 12.7% were newly diagnosed with diabetes. Treatment noncompliance (31.4%), and infection (26.4%) were the main precipitating factors. Most patients presented with moderate DKA (50.9%). Compared to T1DM, patients with Type 2 diabetes (T2DM) were older (53.6 vs 23.9 years, p < 0.001), had longer hospital stay (12.1 days vs 4.1 days, p < 0.001), had more complications (52.1%, vs 18.9% p <0.001), and a higher mortality rate (6.3% vs 0.6%, p = 0.035). Patients with severe DKA had a shorter diabetes duration compared to mild and moderate DKA (5.7 vs 11.0 vs 11.7 years, respectively, p = 0.007), while complications were significantly lower in the mild group compared to both the moderate and severe groups (11.6% vs 32.1% vs 33.3%, respectively). The risk of DKA is higher for patients with T1DM than for those with T2DM. The clinical characteristics and outcomes of patients with T2DM differ from those with T1DM highlighting the importance of educating all patients about DKA.

Diabetic ketoacidosis: a canary in the mine for mental health disorders?

Recurrent diabetic ketoacidosis (DKA) has been linked to mental health disorders, but less is known about single DKA episodes. Most studies are retrospective, lacking control groups. To prospectively examine psychosocial factors in patients presenting with recurrent or single episode DKA and compare with people who have not had DKA. Case-controlled study (consecutive adult DKA admissions April 2015 to December 2016) at Western Health, Melbourne. Data were prospectively collected regarding diagnosed mental health disorders, likely depression (Patient Health Questionnaire (PHQ-9)), diabetes distress (Problem Areas in Diabetes (PAID) questionnaire) and presence of adverse social factors. A control group without a history of DKA was also recruited. Of 123 patients admitted with DKA (164 consecutive episodes), 70 consented to participate and 73 age-matched Type 1 diabetes controls were recruited. Eleven (61%) of 18 with recurrent DKA had a diagnosed mental health disorder versus 8 (19%) of 42 in the single episode group (P = 0.016). The prevalence of likely depression using PHQ-9 was: recurrent 50%; single 40%; and controls 22% (recurrent vs controls, P = 0.036; single vs controls, P = 0.053). Severe diabetes distress (PAID) was present in 47% of recurrent and 34% of single episode DKA (P = 0.387). As a group, DKA patients had significantly more unemployment, illicit drug use and tobacco smoking, a lower level of formal education and less regular medical contact compared with controls. Mental health disorders and adverse socioeconomic factors appear to be common in patients with DKA. The diagnosis of DKA presents an excellent opportunity to screen for depression and offer appropriate intervention.

Hypoglycaemia incidence with a simple, low-dose insulin protocol for adult diabetic ketoacidosis.

The objective of this study is to validate the glycaemic safety of a simple insulin protocol using weight-based insulin rates adapted from American guidance for the management of adult diabetic ketoacidosis. Measures of hypoglycaemia were retrospectively assessed in a single cohort of inpatient adults. The primary outcome was incidence of hypoglycaemia during insulin infusion. Hypoglycaemia during infusion occurred in 6/81 patients (7% [95% CI 3-16%]). Five of these occurrences were associated with protocol nonadherence. The glycaemic safety of a novel, variable-rate insulin protocol directly incorporating weight-based infusion rates is supported by this single-centre study.

Outcomes of Diabetic Ketoacidosis in Adults With End-Stage Kidney Disease: Retrospective Study Based on a National Database

Introduction: The prevalence of diabetes mellitus (DM) in the United States has steadily increased over the past few decades. End-stage kidney disease (ESKD) and diabetic ketoacidosis (DKA) are among the most common chronic and acute complications of DM. Guidance on the management of DKA in ESKD is limited by lack of evidence. We investigated the in-hospital outcomes of patients hospitalized for DKA with underlying ESKD. Methods: We carried out a retrospective cohort study and utilized the National Inpatient Sample (NIS) database from 2016 to 2018. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10 CM) codes were used to identify adults (>18 yrs) diagnosed with DM and ESKD. We compared patients with DKA and ESKD to patients who had DKA with preserved renal function. The primary outcomes were rates of in-hospital mortality and mechanical ventilation. Results:Out of 538,135 patients, 18,685 (3.74%) represented DKA patients with ESKD, and 519,450 (96.53%) represented DKA patients with preserved renal function. DKA with concomitant ESKD was more prevalent in a relatively older population (age>30 yrs) with female predominance (52.4%) (p<0.001). The mean age of males and females in the ESKD group was 46.2 (SD 12.7) and 43.7 (SD 13.6) years respectively. African American race and low socioeconomic status had a higher burden of ESKD. In-hospital mortality rate (adjusted OR= 1.12, p=0.56) and need for mechanical ventilation (adjusted OR= 1.11, p=0.25) did not differ significantly in the two groups but adjusted mean total hospitalization charge ($14,882) and mean length of stay (0.87) at the hospital were significantly higher in patients with DKA and ESRD than in those with preserved renal function.Conclusion: DKA is associated with short-term morbidity, increased length of stay, and cost of hospitalization. There is a dearth of evidence-based guidance regarding DKA management in CKD and ESRD. Further studies looking into measures in the management of DKA in ESRD will help develop guidelines in management, decreasing morbidity, and cost of hospitalization.

Clinical Profile and Outcomes of Diabetic Ketoacidosis during the COVID-19 Pandemic in North India.

Although recent data have shown a declining trend in mortality in diabetic ketoacidosis (DKA), the outcomes are likely to be different during the coronavirus (COVID-19) pandemic. We conducted a prospective cohort study to evaluate the spectrum and outcomes of adult DKA during the pandemic and document differences in DKA patients with or without COVID-19. A total of 169 patients (mean age 44 years) were admitted at the Emergency Department of PGIMER, Chandigarh (India), from January 2020 to June 2021. The precipitating factors were noncompliance with antidiabetic therapy (77.5%), infections (62.7%), and noninfectious conditions (21.3%). Thirty-nine (23.1%) patients had COVID-19, including 31 with severe infection. DKA severity and resolution, ventilator requirement, hospital stay, and mortality were similar in the patients with or without COVID-19. In-hospital mortality was 39.6% (n = 67). The independent mortality predictors were ventilator requirement (p-0.000), an infection trigger (p-0.049), and hyperosmolarity (p-0.048). DKA mortality is increased significantly during the pandemic.

Diabetic ketoacidosis in adults: identification, diagnosis and management

Diabetic ketoacidosis (DKA) is a disordered metabolic state resulting from the combination of absolute or relative insulin deficiency with increased production of counter-regulatory hormones​[1]​. Most episodes of DKA occur in people who have type 1 diabetes mellitus (T1DM); however, those with type 2 diabetes mellitus (T2DM) can experience DKA following catabolic stress (e.g. surgery, trauma and acute […]

Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus

IntroductionWe explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes.Research design and methodsThis observational study...

Comparison of Adult Diabetic Ketoacidosis Treatment Protocols From Canadian Emergency Departments

BackgroundDiabetic ketoacidosis (DKA) is a common acute life-threatening complication of poorly controlled diabetes mellitus contributing to considerable mortality and morbidity. Use of standardized treatment protocols improves patient outcomes in the emergency department (ED) for many conditions, but variability in adult DKA treatment protocols has not been assessed across EDs. In this study, we compared DKA treatment protocols from adult EDs across Canada to highlight inconsistencies in recommended DKA management. MethodsED staff in Canada were solicited for their treatment protocols used to guide acute ED DKA management. Information regarding initial fluid resuscitation and maintenance fluid, potassium replacement, insulin therapy and bicarbonate administration was abstracted from each protocol, collated in a table and compared. ResultsThirty-six unique protocols were obtained representing 85 institutions (40 urban and 45 rural, with a 65.1% response rate) across Canada, with no protocol use for 4 urban centres. Similarities in protocols included the intravenous insulin infusion rate and instructions for switching to subcutaneous insulin. Variability was noted in the rate, amount and type of fluid bolus given (0.5 to 2 L of normal saline or Ringer’s lactate over 15 minutes to 2 hours), the criteria determining the amount, potassium supplementation at normo/hypokalemic ranges, when to add dextrose to maintenance fluid, insulin bolus inclusion and bicarbonate administration. ConclusionsThis is the first comparison of adult DKA treatment protocols in Canada. Although several common approaches were identified, variability was found in initial fluid boluses, initial insulin bolus and role of bicarbonate, necessitating further study to ensure local DKA protocols reflect current evidence-based best practices for optimal patient clinical outcomes.

Mapping the role of pH-adjusted potassium in diabetic ketoacidosis: Hypokalemia and the patient outcomes.

Incidence of hypokalemia during the management of diabetic ketoacidosis (DKA) is high despite detailed potassium replacement guidelines in its treatment. We aimed to find the role of pH-adjusted potassium (pHK ) in the development of hypokalemia, and their mutual impact on patient outcomes during DKA management. Adult DKA patient's admission data of preceding 3years (2015-2017) were retrospectively clerked. Outcomes of interest were time to develop hypokalemia and to terminate emergency department (ED) care (hours), severity of hypokalemia and hospitalisation length (days). Linear regression was used to determine significant associations/predictors. The study was concluded on 85 patients. Hypokalemia was observed in nearly 3/4th of all admissions and occurred by the time of ED care termination. Each 1mmol/L increase in pHK significantly (a) reduced the degree of hypokalemia by 0.07mmol/L, (b) delayed time to develop hypokalemia by 4.58hours, (c) and reduced the ED care time by 1.28hours. Arterial pH was the other factor significantly delaying time to develop hypokalemia (36.25hours) and facilitating early discharge from ED (13.86hours). Moreover, each 1mmol/L reduction in the degree of hypokalemia increased hospitalisation length by 1.86days. Though significant, acute kidney injury negligibly increased hospitalisation length by 0.01days. pH-adjusted potassium shall be used as a marker for hypokalemia and to initiate potassium replacement instead of measured serum potassium in DKA. Utilising pHK will help to avoid hypokalemia, reduce its severity and shorten ED care which will subsequently reduce hospitalisation length. We expect pHK to improve pharmacoeconomics in the future.

A Multi-Intervention Campaign Lowers Pediatric and Young Adult Diabetic Ketoacidosis Hospitalizations in a Canadian Province

ObjectivesThe Newfoundland and Labrador diabetic ketoacidosis Project (NLdkaP) is a multi-intervention, province-wide project aimed at lowering rates of diabetic ketoacidosis (DKA) within the pediatric and young adult populations. MethodsThe NLdkaP interventions were first selected, developed and implemented. We then conducted a retrospective study of hospitalization data over three 2-year periods: pre-, during and post-NLdkaP. Data included demographic factors, DKA hospitalizations and length of hospital stay. ResultsThere were 412 DKA hospitalizations over the study period. Before the NLdkaP, the provincial hospitalization rate of DKA for patients <25 years of age was 55.61 per 100,000. During the NLdkaP, the rate dropped to 38.48 per 100,000 (p<0.001). After the NLdkaP, the rate rose to 54.53 per 100,000 (p<0.001). Hospitalization rates were highest for females (p<0.001) and for those in the 19- to 24-year age group (p<0.001). ConclusionsThe NLdkaP was associated with decreased rates of DKA hospitalizations, but the rates remained relatively stable in both the pre- and postintervention periods. Although the approach and resources developed in the NLdkaP appear effective, continuous preventive efforts are needed to sustain reductions in DKA hospitalizations.