Diabetic Ketoacidosis Patients Research Articles

Comparison of admissions for diabetic ketoacidosis in patients with autoimmune diabetes and type 2 diabetes in the san cecilio clinic university hospital

Comparison of admissions for diabetic ketoacidosis in patients with autoimmune diabetes and type 2 diabetes in the san cecilio clinic university hospital

D-31 | Impact of Diabetic Ketoacidosis in Patients with Cardiogenic Shock

D-31 | Impact of Diabetic Ketoacidosis in Patients with Cardiogenic Shock

Practical method in the diagnosis of diabetic ketoacidosis: end-tidal carbon dioxide

Objectives: Diabetic ketoacidosis (DKA) poses a life-threatening risk in uncontrolled diabetes. Current diagnostic criteria rely on invasive measures, leading to potential delays in treatment initiation. This study aimed to assess the diagnostic utility of noninvasive end-tidal carbon dioxide (EtCO2) measurements in DKA patients. Methods: A prospective, cross-sectional study was conducted in a tertiary-level Emergency Medicine Clinic from January 2021 to January 2023. Participants included adults with DKA symptoms and those with stable vital signs as controls. EtCO2 levels were measured using a capnograph device. Diagnostic criteria for DKA were blood glucose ≥250 mg/dL, ketonuria, ketonemia, and metabolic acidosis (pH<7.3 or bicarbonate <15 mEq/dL). Statistical analysis was performed using SPSS Statistics. Results: Of 730 participants, 120 had DKA, 410 did not, and 200 served as controls. EtCO2 levels significantly differed between DKA, non-DKA, and control groups (P<0.05). EtCO2 correlated with pH, lactate, base deficit, and bicarbonate (P<0.05). ROC analysis showed an AUC of 0.86 for EtCO2 in diagnosing DKA (P<0.01), with 91.67% sensitivity and 74.39% specificity at a cut-off value 23.7. Conclusion: This study suggests that EtCO2 measurement is a valuable noninvasive tool for diagnosing and assessing the severity of DKA in the emergency department. An EtCO2 threshold of <23.7 could prompt consideration of DKA in patients with elevated blood glucose levels. More extensive multicenter studies are warranted to validate these findings further. EtCO2 measurement could facilitate early DKA diagnosis and improve patient outcomes.

Sodium bicarbonate and intubation in severe diabetic ketoacidosis: are we too quick to dismiss them?

Management of diabetic ketoacidosis (DKA) has internationally established guidelines. However, management of severe, refractory DKA with multiple contributors to acidosis, and management of DKA in patients with altered mentation, remain ambiguous. Use of sodium bicarbonate and intubation in DKA are unpopular treatment practices, but warrant consideration in these unique clinical scenarios. This paper describes a 61-year-old Sri Lankan female who presented with severe DKA, seizures and altered level of consciousness. In her case, the acidosis was secondary to DKA, hyperlactatemia, hyperchloraemic acidosis and acute kidney injury (AKI). Intravenous sodium bicarbonate was used in the management of acidosis. She was intubated due to altered level of consciousness with inadequate respiratory drive to compensate for metabolic acidosis. The outcome in her case was favorable. Intravenous sodium bicarbonate in DKA should be considered for patients with severe, refractory acidosis with hemodynamic instability, hyperkalemia and compounding acidosis due to normal anion gap acidosis or AKI. Intubation should be considered for patients with obtunded mentation unable to achieve respiratory compensation and obtunded mentation where reversal of DKA is unlikely to improve consciousness. Both strategies should be personalized with consideration of individual risk vs benefit.

Variations in Management and Clinical Outcomes for Children With Diabetic Ketoacidosis in an Academic Pediatric Versus Community Emergency Department Setting.

Our objectives were to characterize variations from standardized, evidence-based guidelines in the management of pediatric patients with diabetic ketoacidosis (DKA) based on initial presentation to a tertiary pediatric emergency department (PED) versus a community emergency department (OSH) and compare clinical outcomes. We conducted a retrospective study on children 18 years and younger with DKA who presented to an OSH or PED over a 3-year period. Treatments monitored for variation included intravenous fluid management, insulin delivery, and sodium bicarbonate administrations. Clinical outcomes included time to anion gap correction and on insulin infusion, hypokalemia, hypoglycemia, rapid serum glucose decline, cerebral edema, mechanical ventilation, mortality, and time from initial presentation to hospital discharge. Children with DKA who presented to an OSH (n = 250) were more acidotic (pH 7.11 vs. 7.13, P = 0.001) and had larger anion gaps (28.8 vs. 25.5, P < 0.001) compared with children presenting to the PED (n = 237). The OSH patients were more likely to receive larger fluid boluses (>20 cc/kg or >1000 ml, 43% vs. 4%, P < 0.001), sodium bicarbonate (5% vs. 0%, P < 0.001), and intravenous bolus insulin (28% vs. 0%, P < 0.001). The OSH group were less likely to be started on maintenance intravenous fluids (70% vs. 99%, P < 0.001) or receive potassium in maintenance intravenous fluids (14% vs. 42%, P < 0.001). The OSH group had longer anion gap correction times (754 vs. 541 mins, P < 0.001), insulin infusion times (1018 vs. 854 min, P = 0.003), and times to hospital discharge (3358 vs. 3045 mins, P < 0.001). Incidence of hypokalemia, hypoglycemia, rapid glucose decline, cerebral edema, and deaths were similar between the 2 groups. Our study demonstrated significant variations in the initial management of pediatric DKA patients by OSH facilities that deviated from an evidence-based treatment pathway utilized by a PED. Statewide quality improvement initiatives could help improve the overall clinical care provided to pediatric DKA patients.

Risk of Diabetic Ketoacidosis Associated with Sodium Glucose Cotransporter-2 Inhibitors: A Network Meta-Analysis and Meta-Regression.

Background: Sodium glucose cotransporter-2 inhibitors (SGLT2is) represent an emerging class of drugs with diverse indications. Despite their therapeutic potential, concerns regarding safety, particularly diabetic ketoacidosis (DKA), remain contentious, with uncertainty regarding differences among various SGLT2is. This study aimed to conduct a network meta-analysis and meta-regression to evaluate the risk of SGLT2i-induced DKA and associated factors. Methods: We systematically searched electronic databases for randomized clinical trials assessing SGLT2is across indications, reporting incidences of DKA. Mixed treatment comparison pooled estimates (MTCPEs) were calculated, and odds ratios (OR) with 95% confidence intervals (95% CI) served as effect estimates. We analyzed differences across dose categories (low, medium, and high) and conducted a meta-regression analysis to identify risk factors. The strength of evidence for key comparisons was determined. Results: Our analysis included 73 articles encompassing 85,997 participants assessing the risk of DKA. SGLT2is were associated with a heightened risk of DKA compared to placebo/control interventions (OR: 1.83; 95% CI: 1.35, 2.46), a finding confirmed by bootstrap analysis. Among SGLT2is, dapagliflozin (OR: 1.9; 95% CI: 1.17, 3.08), sotagliflozin (OR: 1.93; 95% CI: 1.14, 3.25), canagliflozin (OR: 1.11; 95% CI: 1.11, 12.45), and ertugliflozin (OR: 3.92; 95% CI: 1.04, 14.77) exhibited increased DKA risk. No significant differences were observed among specific SGLT2is. Sub-group analyses revealed a high risk of DKA with low (OR: 1.98; 95% CI: 1.3, 2.95) and high doses (OR: 2.4; 95% CI: 1.7, 3.3), type 1 diabetes (OR: 3.6; 95% CI: 1.6, 8.1), type 2 diabetes (OR: 1.6; 95% CI: 1.3, 2.4), as well as a diabetes duration exceeding 10 years (OR: 3.4; 95% CI: 1.1, 10.8). The evidence of certainty for most comparisons was moderate. Conclusions: SGLT2 inhibitors (SGLT2is) have been found to elevate the risk of DKA. The key factors that significantly predict the likelihood of DKA include the presence of diabetes (whether T1D or T2D) and the duration of diabetes. Based on these findings, standard treatment guidelines should advise taking specific precautions against DKA in patients identified as high-risk.

Blood Urea Nitrogen to Serum Albumin Ratio as A New Prognostic Indicator in Critically Ill Patients with Diabetic Ketoacidosis: A Retrospective Cohort Study.

Diabetic ketoacidosis (DKA) remains a life-threatening medical emergency. Blood urea nitrogen to serum albumin (BAR) demonstrated good predictive ability in the mortality of patients with various diseases. The study aimed to investigate the predictive value of BAR for in- and out-of-hospital mortality in critically ill patients with DKA. Data were obtained from the Medical Information Mart for Intensive Care III (MIMIC-III) database and all the eligible subjects were divided into two groups by a cutoff value of BAR. The multiple logistic regression analysis was conducted to determine the association between BAR and in-hospital mortality. The predictive performance of BAR was evaluated by Kaplan-Meier (K-M) analysis. Propensity score matching (PSM) was applied to control confounding factors between the low BAR and high BAR groups. A total of 589 critically ill DKA patients were enrolled. DKA patients with a higher BAR level were associated with higher in-hospital mortality and out-hospital mortality (all p<0.001). There was a significant four-year survival difference between the low and high BAR groups (p<0.0001). After PSM analysis, two PSM groups (202 pairs, n = 404) were generated, and similar results were observed in the K-M curve (p<0.0001). Elevated levels of BAR were associated with an increased risk of in-hospital mortality in critically ill patients with DKA, and BAR could be an independent prognostic factor in in-hospital mortality and out-hospital mortality for patients diagnosed with DKA.

Revised one-bag IV fluid protocol for pediatric DKA: a feasible approach and retrospective comparative study.

This study compared the effectiveness of the traditional and revised one-bag protocols for pediatric diabetic ketoacidosis (DKA) management. This single-center retrospective cohort study included children diagnosed with DKA upon admission between 2012 and 2019. Our institution reevaluated and streamlined the traditional one-bag protocol (revised one-bag protocol). The revised one-bag protocol rehydrated all pediatric DKA patients with dextrose (5 g/100 ml) containing 0.45% NaCl at a rate of 3500 ml/m2 per 24 h after the first 1 h bolus of normal saline, regardless of age or degree of dehydration. This study examined acidosis recovery times and the frequency of healthcare provider interventions to maintain stable blood glucose levels. The revised one-bag protocol demonstrated a significantly shorter time to acidosis recovery than the traditional protocol (12.67 and 18.20 h, respectively; p < 0.001). The revised protocol group required fewer interventions for blood glucose control, with an average of 0.25 dextrose concentration change orders per patient, compared to 1.42 in the traditional protocol group (p < 0.001). Insulin rate adjustments were fewer in the revised protocol group, averaging 0.52 changes per patient, vs. 2.32 changes in the traditional protocol group (p < 0.001). The revised one-bag protocol for pediatric DKA is both practical and effective. This modified DKA management achieved acidosis recovery more quickly and reduced blood glucose fluctuations compared with the traditional one-bag protocol. Future studies, including randomized controlled trials, should assess the safety and effectiveness of the revised protocol in a broad range of pediatric patients with DKA.

A Narrative Review on Diabetic Ketoacidosis in Children.

Diabetic ketoacidosis (DKA) is a life-threatening complication in children with diabetes mellitus. There are considerable differences in the management approaches for DKA between different countries. One of the main areas of differences between guidelines is the administration of fluid, with most guidelines adopting a restrictive approach. This is based on the concern over cerebral oedema, a lethal sequela allegedly to be caused by excessive fluid administration. However, in recent years, new clinical studies suggest that there is no causal relationship between intravenous fluid therapy and DKA-related cerebral injury. The British Society of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to fluid administration, which has sparked controversy among some paediatricians. The purpose of this article is to provide a narrative review on the management of DKA. A PubMed search was performed with clinical queries using the key term "diabetic ketoacidosis". The search strategy included randomized controlled trials, clinical trials, meta-analyses, observational studies, guidelines, and reviews. The search was restricted to English literature and the age range of 18 years and younger. Moreover, we reviewed and compared major guidelines. The management of DKA involves early recognition, accurate diagnosis, meticulous fluid and insulin treatment with close monitoring of blood glucose, ketones, electrolytes, renal function, and neurological status. There is still limited clinical evidence to support either a restrictive or permissive approach in the fluid management of paediatric DKA patients. Clinicians should exercise caution when applying different guidelines in their clinical practice, considering the specific circumstances of individual paediatric patients.

Pathology of Ketoacidosis in Emergency of Diabetic Ketoacidosis and Alcoholic Ketoacidosis: A Retrospective Study.

This study is aimed at examining which factors are useful for the diagnosis and distinction of ketoacidosis. We recruited 21 diabetic ketoacidosis (DKA) and alcoholic ketoacidosis (AKA) patients hospitalized in Kawasaki Medical School General Medical Center from April 2015 to March 2021. Almost all patients in this study were brought to the emergency room in a coma and hospitalized. All patients underwent blood gas aspiration and laboratory tests. We evaluated the difference in diagnosis markers in emergencies between DKA and alcoholic ketoacidosis AKA. Compared to AKA patients, DKA patients had statistically higher values of serum acetoacetic acid and lower values of serum lactate, arterial blood pH, and base excess. In contrast, total ketone bodies, β-hydroxybutyric acid, and β-hydroxybutyric acid/acetoacetic acid ratio in serum did not differ between the two patient groups. It was shown that evaluation of each pathology such as low body weight, diabetes, liver dysfunction, and dehydration was important. It is important to perform differential diagnosis for taking medical histories such as insulin deficiency, alcohol abuse, or starvation as the etiology in Japanese subjects with DKA or AKA. Moreover, it is important to precisely comprehend the pathology of dehydration and alcoholic metabolism which would lead to appropriate treatment for DKA and AKA.

The Prevention of Diabetic Ketoacidosis in Patients with Type 2 Diabetes on Sodium-Glucose Transport Protein 2 Inhibitors

Background: Sodium-Glucose Transport Protein 2 Inhibitors (SGLT2Is) effectively control diabetes. Diabetic ketoacidosis (DKA) has been reported as a life-threatening adverse effect due to SGLT2Is use. Aim: This study aims to review the current evidence of incidence, predisposing factors and the prevention of DKA in T2DM patients on SGLT2Is use. Methods and Materials: Two reviewers have conducted a search strategy of studies published in English between August 2012 and November 2020, in EBSCOhost, Google Scholar, PubMed, Science Direct and Wiley. Two reviewers independently assessed the eligibility and quality of the studies and extracted the data. Results: 85 studies were identified in the initial search; 75 records were removed and finally, 10 studies were included. Only studies discussing the prevention of DKA in T2DM patients on SGLT2Is were selected, extracted and categorized into main domains that included SGLT2Is use inT2DM patients and DKA (50%), SGLT2Is use in T2DM patients (20%), the clinical presentation of DKA (20%) and DKA prevention (10%). Six studies showed SGLT2Is increased the risk of DKA with very low rates in two studies. The precipitating factors of DKA in all included studies were revealed asstopping or reducing insulin, trauma, infection, surgery, severe acute illness, vigorous exercise, dehydration, low carbohydrate intake and excessive alcohol intake. In two studies DKA can be prevented by wakefulness and education, in one study by closed follow-up, in one study by regular monitoring and adjustment of medications and in two studies by recognition of patients at risk. Conclusions: This review summarized the prevention of DKA in T2DM patients on SGLT2Is use with consideration of incidence, a summary of evidence and predisposing factors. Physicians, health care providers and patients should be aware of SGLT2Is use, regular follow up, precipitating factors, symptoms, signs and prevention of DKA. Keywords: Sodium-Glucose Transport Protein 2 Inhibitors SGLT2Is, Type 2 diabetes mellitus, Diabetic Ketoacidosis, Scoping Review.

Clinical findings of acute necrotizing esophagitis complicated by diabetic ketoacidosis.

Acute necrotizing esophagitis (ANE) is a rare and potentially life-threatening complication of diabetic ketoacidosis (DKA). While its association with DKA is established, specific clinical characteristics that predict ANE in DKA patients remain less understood. This study aimed to identify these characteristics by analyzing data from 30 DKA patients admitted from January 2018 to September 2022. Seven patients in this study presented with ANE, forming the ANE group. The remaining 23 constituted the non-ANE group. We compared the clinical parameters and computed tomography (CT) between the groups. The mean age of participants was 57.7 ± 20.4 years, and their mean HbA1c was 11.1 ± 3.3%. Notably, ethanol intake was significantly higher in the ANE group (44.4 ± 25.4 g/day) compared to the non-ANE group (6.8 ± 14.0 g/day; p = 0.013). Additionally, sodium-glucose transport protein 2 inhibitor use was significantly more prevalent in the ANE group (p = 0.013). Gastrointestinal symptoms were also significantly more pronounced in the ANE group, with vomiting occurring in 85.7% of patients compared to only 13.0% in the non-ANE group. Admission CT scans revealed further distinguishing features, with the ANE group showing significantly higher rates of esophageal wall thickening, intra-esophageal effusion, and calcification of the celiac artery origin (p < 0.0001, 0.0038, 0.0038, respectively). In conclusion, our study suggests that heavy alcohol consumption and strong gastrointestinal symptoms in DKA patients warrant a heightened suspicion of ANE. Early consideration of CT or upper gastrointestinal endoscopy is recommended in such cases.

Diabetic Ketoacidosis in Type 1 Diabetes Mellitus

Introduction: Diabetic ketoacidosis (DKA) is a state of metabolic decompensation/disorder characterized by the triad of hyperglycemia, acidosis and ketosis, caused by absolute or relative insulin deficiency and increased counter-regulatory hormones. Immediate therapy in DKA patients determines the patient's prognosis Case Report: A 19-year-old male treated in the internal medicine ward of Dr. M djamil Padang with diabetic ketoacidosis, type 1 DM, and Abscess capitis. The patient was treated with rehydration and intravenous insulin infusion can show clinical improvement. Conclusion: The diagnosis in patients is based on anamnesis, physical examination and supporting examinations. Immediate therapy is needed in the management of DKA in patients. After DKA is resolved, look for the causes of the risk of DKA. On the third day of treatment the patient's condition improved clinically and the laboratory.

Outcome of adults with diabetic ketoacidosis admitted to intensive care unit: a retrospective study.

Background: Numerous advancements in diabetes care have been made over the past 20 years. Few studies discussed the outcome and predictors of diabetic ketoacidosis (DKA) necessitating admission to intensive care units (ICU). We, therefore, performed a retrospective analysis of DKA patients admitted to King Saud Medical City\&amp;apos;s ICU between August 2022 and August 2023 to examine trends in outcome and predictors. Method: Patients with DKA episodes who visited the emergency room at King Saud Medical City in Riyadh, Saudi Arabia, between August 2022 and August 2023 were included in this retrospective analysis. Every adult patient, who met the American Diabetes Association\&amp;apos;s requirements for DKA diagnosis and was at least 18 years old, was included. Results In the final analysis, we included 218 patients with DKA, of whom 56 (25.6) were under ICU care. The patients admitted to the ICU had higher BMI and were more likely to be male than non-ICU patients, they were also having advanced age. DKA patients with type 2 diabetes mellitus (T2DM) had a higher likelihood of ICU admission than those with T1D. In patients with DKA needed ICU care, WBC counts were higher, as were urea level, and CRP. Compared to patients who did not need ICU admission, those who needed to be admitted had lower venous pH level and bicarbonate levels. Furthermore, 3.5% of ICU-admitted patients died in hospital, compared to 0 deaths among non-ICU admitted patients. Conclusion: Of all patients with DKA, 25.6% needed ICU. Some factors that indicate a patient\&amp;apos;s likelihood of needing an ICU were; T2DM, advanced age, an infectious cause, newly diagnosed diabetes, and moderate or severe DKA.

Hidden in Plain Sight: The Association of Cystic Fibrosis and Diabetic Ketoacidosis- A Nationwide Study

BackgroundIn recent times, the relationship between cystic fibrosis (CF) and diabetic ketoacidosis (DKA) has garnered growing interest within the medical community. This study aims to investigate the cardiovascular(CV) outcomes and economic ramifications associated with CF patients with DKA,using the United States National Readmission Database(NRD). Methods and ResultsWe examined data from 2016-2020 and excluded patients under the age of 4, identifying 73,125 hospitalizations for cystic fibrosis (CF). Of these,9.18% (n=6,719) were diagnosed with diabetic ketoacidosis (DKA). The DKA cohort had a higher mean age (43 years,SD-18.5 vs 29 years,SD-16.3;p=0.000). Baseline-comorbidities were shown in Figure1. DKA in CF has been identified as a predictor for all-cause-mortality[OR2.3,95%CI 1.8-3,p= 0.000], Acute kidney Injury(AKI)[OR 2.99,95%CI 2.65-3.37,p=0.000], Congestive-Heart-Failure(CHF)[OR 5.36,95%CI 4.58-6.27,p=0.000], Stroke [OR 4.93,95%CI 2.97-8.18,p=0.000], Myocardial infarction(MI)[OR 5.06,95%CI 3.20-8.00,p=0.000], SCA [OR 2.82,95%CI 1.77-4.49,p=0.000], Mechanical-Circulatory-Support(MCS)[OR 2.00,95%CI 1.07-3.75,p=0.030], Major-adverse-cardiovascular-and-cerebrovascular-events(MACCE)[OR 2.95,95%CI 2.35-3.69, p=0.000], Figure-2. In terms of economic impact, CF patients with DKA experienced a higher average inflation-adjusted hospitalization cost ($113,635-vs-$102,622,p=0.0144). However, the difference in the mean length of hospitalization was not clinically meaningful (7.9-vs-8.4 days,p=0.0137). ConclusionsAdverse CV outcomes and increased mortality in DKA patients with CF are influenced by metabolic stress, electrolyte imbalances, inflammation, co-existing comorbidities, and reduced lung function. These factors heighten the cardiovascular risk, requiring attentive monitoring and management by healthcare providers. Enhanced research efforts are essential to comprehensively understand the CF-DKA relationship, paving the way for more effective strategies to manage cardiovascular risks and improve patient outcomes.

Associations Between Postdischarge Care and Cognitive Impairment-Related Hospital Readmissions for Ketoacidosis and Severe Hypoglycemia in Adults With Diabetes.

Patients with severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) experience high hospital readmission after being discharged. Cognitive impairment (CI) may further increase the risk, especially in those experiencing an interruption of medical care after discharge. This study examined the effect modification role of postdischarge care (PDC) on CI-associated readmission risk among U.S. adults with diabetes initially admitted for DKA or SH. We used the Nationwide Readmissions Database (NRD) (2016-2018) to identify individuals hospitalized with a diagnosis of DKA or SH. Multivariate Cox regression was used to compare the all-cause readmission risk at 30 days between those with and without CI identified during the initial hospitalization. We assessed the CI-associated readmission risk in the patients with and without PDC, an effect modifier with the CI status. We identified 23,775 SH patients (53.3% women, mean age 65.9 ± 15.3 years) and 140,490 DKA patients (45.8% women, mean age 40.3 ± 15.4 years), and 2,675 (11.2%) and 1,261 (0.9%), respectively, had a CI diagnosis during their index hospitalization. For SH and DKA patients discharged without PDC, CI was associated with a higher readmission risk of 23% (adjusted hazard ratio [aHR] 1.23, 95% confidence interval 1.08-1.40) and 35% (aHR 1.35, 95% confidence interval 1.08-1.70), respectively. However, when patients were discharged with PDC, we found PDC was an effect modifier to mitigate CI-associated readmission risk for both SH and DKA patients (P < 0.05 for all). Our results suggest that PDC can potentially mitigate the excessive readmission risk associated with CI, emphasizing the importance of postdischarge continuity of care for medically complex patients with comorbid diabetes and CI.

Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis.

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.

FREQUENCY OF RISK FACTORS ASSOCIATED WITH DIABETIC KETOACIDOSIS IN PATIENTS PRESENTING AT KHYBER TEACHING HOSPITAL PESHAWAR

Objectives: To determine the frequency of risk factors associated with diabetic ketoacidosis in patients presenting at Khyber Teaching Hospital Peshawar. Materials and methods: Patients of either gender, aged between 18 and 60 years, with either type I or type II diabetes mellitus presenting with diabetic ketoacidosis with the duration of diabetes &gt; 1 year were included in the study. DKA was diagnosed based on the clinical presentation of respective patients, serum Random Blood Sugar (RBS), and urinary ketones. Careful scrutinization was done for the detection of common risk factors for DKA like infections, stroke, myocardial infarction, and pancreatitis. Based on the clinical examination for Stroke and acute pancreatitis, CT imaging of the brain and CT of the abdomen with pancreatic protocol were performed. Results: Among 111 DKA patients, the mean age was 43 years with standard deviation ± 12.05. 63(57%) patients were male while 48(43%) were female. Infection was found in 54(49%) patients, stroke in 4(4%) myocardial infarctions in 3(3%), and pancreatitis was found in 7(6%) patients. Conclusion: The most common risk factor for diabetic ketoacidosis is infections in half of the participants while stroke was 4%, myocardial infarction was 3% and pancreatitis was 6%.     KEYWORDS: diabetic ketoacidosis; type I diabetes; type II diabetes

The effectiveness of blood glucose and blood ketone measurement in identifying significant acidosis in diabetic ketoacidosis patients

BackgroundPatients with diabetic ketoacidosis (DKA), a potentially fatal complication of type 1 diabetes, have hyperglycemia, ketonemia and metabolic acidosis. Blood glucose and blood ketone results are often used to triage patients with suspected DKA. This study aimed to establish how effective blood glucose and blood ketone (beta-hydroxybutyrate, BOHB) measurements are in identifying patients with significant acidosis and sought to validate existing diagnostic BOHB thresholds.MethodsInitial Emergency Department results on 161 presumptive DKA episodes in 95 patients (42 F, 53 M, age range 14–89 years) containing a complete dataset of D (glucose), K (BOHB) and A (Bicarbonate [HCO3] and pH) results.ResultsBlood glucose correlated poorly with BOHB (r = 0.28 p = 0.0003), pH (r= -0.25, p = 0.002) and HCO3 (r= -0.17, p = 0.04). BOHB, though better, was still limited in predicting pH (r = -0.44, p < 0.0001) and HCO3 (r = -0.49, p < 0.0001). A HCO3 of 18mmol/L equated to a BOHB concentration of 4.3mmol/L, whilst a HCO3 of 15mmol/L equated to a BOHB of 4.7mmol/L. Of the 133 of 161 events with HCO3 < 18mmol/L, 22 were not hyperglycemic (> 13.9mmol/L, n = 8), ketonemic (≤ 3mmol/L, n = 9) or either (n = 5).ConclusionsThe commonly employed BOHB diagnostic cutoff of 3mmol/L could not be verified. Since acid-base status was poorly predicted by both glucose and BOHB, this highlights that, regardless of their results, pH and/or HCO3 should also be tested in any patient suspected of DKA.

THU387 Euglycemic Diabetic Ketoacidosis And SGLT-2 Inhibitor Use

Abstract Disclosure: N. Abrahimi: None. A. Abrahimi: None. N. Terrigno: None. Background: Diabetic ketoacidosis (DKA) is a known adverse effect of SGLT-2 inhibitors. (1) Incidences of euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors are reported on less. Clinical Case: A 39-year-old male past medical history of uncontrolled, non-insulin dependent diabetes mellitus and pancreatitis who presented with abdominal pain, nausea and coffee ground emesis. On initial work up, basic metabolic panel showed blood glucose level of 175 mg/dL with an elevated anion gap of 22 mmol/L. Initial differentials included suspicion for euglycemic diabetic ketoacidosis or acute intraabdominal pathology. Venous blood gas showed metabolic acidosis, with a pH of 7.21 and bicarbonate of 9.7 mmol/L, beta hydroxybutyrate was elevated at 7.83 mmol/L. CT abdomen pelvis found a small hiatal hernia, gastric wall thickening, likely gastritis, and was negative for other intraabdominal pathology. Home medications of the patient included dapagliflozin, semaglutide, metformin, gabapentin, and pantoprazole. Patient was admitted with the diagnosis of suspected euglycemic diabetic ketoacidosis and was started on an insulin drip along with D5 0.45 normal saline. Patient’s anion gap was monitored with basic metabolic panel orders every two hours. The insulin drip was discontinued once the patient had two consecutive normal anion gaps and the patient was subsequently started on a subcutaneous insulin regimen. Conclusion: SGLT-2 inhibitors may cause euglycemic diabetic ketoacidosis based on the physiology of the SGLT-2 transporter and the pharmacology of the SGLT-2 inhibitors. (2) Clinical importance of this case report is to consider euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors presenting with nausea, vomiting with normal blood glucose to not delay in the diagnosis and treatment of this life-threatening condition.