Resolution Of Diabetic Ketoacidosis Research Articles

Comparison of balanced crystalloids versus normal saline in patients with diabetic ketoacidosis: a meta-analysis of randomized controlled trials

PurposeThe optimal resuscitative fluid for patients with diabetic ketoacidosis (DKA) remains controversial. Therefore, our objective was to assess the effect of balanced crystalloids in contrast to normal saline on clinical outcomes among patients with DKA.MethodsWe searched electronic databases for randomized controlled trials comparing balanced crystalloids versus normal saline in patients with DKA, the search period was from inception through October 20th, 2023. The outcomes were the time to resolution of DKA, major adverse kidney events, post-resuscitation chloride, and incidence of hypokalemia.ResultsOur meta-analysis encompassed 11 trials, incorporating a total of 753 patients with DKA. There was no significant difference between balanced crystalloids and normal saline group for the time to resolution of DKA (MD -1.49, 95%CI -4.29 to 1.31, P=0.30, I2 = 65%), major adverse kidney events (RR 0.88, 95%CI 0.58 to 1.34, P=0.56, I2 = 0%), and incidence of hypokalemia (RR 0.80, 95%CI 0.43 to 1.46, P=0.46, I2 = 56%). However, there was a significant reduction in the post-resuscitation chloride (MD -3.16, 95%CI -5.82 to -0.49, P=0.02, I2 = 73%) among patients received balanced crystalloids.ConclusionAmong patients with DKA, the use of balanced crystalloids as compared to normal saline has no effect on the time to resolution of DKA, major adverse kidney events, and incidence of hypokalemia. However, the use of balanced crystalloids could reduce the post-resuscitation chloride.Systematic review registrationhttps://osf.io, identifier c8f3d.

Pembrolizumab-induced type 1 diabetes.

Immunotherapy has a crucial role in the current treatment of multiple malignancies. Albeit described as rare, new onset autoimmune diabetes is a potentially life-threatening complication of programmed cell death-1 (PD-1) inhibitors, such as pembrolizumab, and its predisposing factors and pathological mechanism are yet to be clarified. We present a case of a 72-year-old man with a high-grade bladder carcinoma undergoing pembrolizumab treatment. He had no personal or family history of diabetes mellitus but was diagnosed with primary hypothyroidism four months after starting pembrolizumab. Two years after starting pembrolizumab, he presented in the emergency department due to abdominal pain, anorexia, polydipsia, polyuria and vomiting over the preceding five days and he met criteria for severe diabetic ketoacidosis (DKA). Three days prior to his admission, he had received prednisolone therapy for suspected hypersensitivity related to a contrast-enhanced imaging that he performed. Prompt treatment for DKA was started, with transition to insulin basal-bolus therapy after DKA resolution, with progressive glycaemic stabilization. Further investigation revealed low C-peptide levels (0.07 ng/dL, with a fasting blood glucose of 288 mg/dL), HbA1c 9.2% and positive anti-IA2 antibodies, which allowed the diagnosis of new-onset autoimmune diabetes. Pembrolizumab was transiently suspended, and the patient resumed treatment after glycaemic profile optimization under multiple daily insulin administrations two months later. This case highlights the importance of clinical suspicion and glycaemic monitoring as an integral part of treatment protocols in patients on pembrolizumab and other immune checkpoint inhibitors. Additional research and investigation into the underlying mechanisms of this condition are necessary to identify potential screening tests for individuals at higher risk of developing DM and to guide the implementation of management and preventive strategies for ketoacidosis complication.

Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis.

Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip. Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001). In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.

Success of Insulin Infusion Transitions in Moderate to Severe Diabetic Ketoacidosis With Transition Anion Gap of Less Than or Equal to 12 mEq/L Versus Greater Than 12 mEq/L.

Background: Patients with diabetic ketoacidosis (DKA) are transitioned from intravenous (IV) to subcutaneous (SQ) insulin upon DKA resolution. Although an anion gap (AG) ≤12 mEq/L is recommended before transition to SQ insulin, there are limited data to support this threshold. Objective: To compare the rates of successful transitions to SQ insulin in patients with DKA with an AG ≤ 12 mEq/L versus > 12 mEq/L. Methods: Retrospective cohort study of adult critically ill patients with moderate to severe DKA between September 2019 and December 2022. The primary outcome was the success of insulin transition between patients transitioned with an AG ≤ 12 mEq/L and those transitioned with an AG > 12 mEq/L. Transition was considered successful if the AG did not increase above the value at transition at 24 hours and insulin infusion was not restarted. Secondary outcomes include the individual components of the primary outcome and ICU length of stay (LOS); safety outcomes included hypoglycemia and electrolyte derangements. Results: In total, 92 patients were included, with 43 patients transitioned at AG ≤ 12 mEq/L and 49 patients transitioned at AG > 12 mEq/L. Transition was unsuccessful in 3 patients (7%) with AG ≤ 12 mEq/L and 2 patients (4%) with AG > 12 mEq/L (P = .66). There was no difference in the incidence of the individual components of this outcome between groups or in safety outcomes. Conclusion: This retrospective study showed no difference in success of insulin transition between the groups. Larger studies are needed to evaluate the impact of treatment characteristics on transition success and patient outcomes.

Clinical and Biochemical Characteristics of Pediatric Diabetic Ketoacidosis Admissions to COVID-19 Free UAE Tertiary Center during Pandemic

Background: COVID-19 pandemic led to delayed diagnosis and increase in number and severity of type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis (DKA) cases in pediatric population worldwide. The indirect impact of the pandemic on pediatric DKA admissions to COVID-19-free hospitals worth to be evaluated. Objectives: Our aim was to evaluate the characteristics and severity of DKA admissions before and during the pandemic to COVID-19-free hospital. Methods: This descriptive retrospective study included 130 episodes of DKA for patients aged below 16 years admitted to Tawam Hospital, a COVID-19-free hospital, between March 2017 and Feb 2021. Data from March 2020 to Feb 2021 (pandemic) were compared to the previous 3 years, March 2017 to Feb 2020 (pre-pandemic). Data were retrieved from the electronic records and analyzed using STATA13. Results: We evaluated 130 DKA admissions (63 pandemic and 67 pre-pandemic). The majority of patients in the pandemic group were in, the age group of (6–11.9 years) (54% vs. 23.9%, p = 0.001), and higher proportion of them was diagnosed with new-onset diabetes (42.9% vs. 25.4%, p = 0.035). Overall, there was no significant difference in symptoms duration, DKA severity, or time to DKA resolution, but there was a difference in the median (IQR) HbA1C, 11% (9.4–12.95) vs. 10.15% (9.27–11.80) (p = 0.0297) in the pandemic and pre-pandemic groups, respectively. Conclusion: In our COVID-19-free hospital, the pandemic and service reallocation has led to an increased rate of DKA admissions with increased number of newly diagnosed T1DM. Clinical presentation and severity were not adversely affected.

Balanced crystalloids (RInger’s lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a pilot randomised controlled trial

BackgroundCurrent diabetic ketoacidosis (DKA) treatment guidelines recommend using normal saline (NS); however, NS may delay DKA resolution by causing more hyperchloremic metabolic acidosis compared with balanced crystalloids. This study’s objective...

Rehydration Rates and Outcomes in Overweight Children With Diabetic Ketoacidosis.

The Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (DKA) (FLUID) Trial found that rapid fluid infusion does not increase the risk of cerebral injury. Concern persists, however, whether fluid rates should be adjusted for overweight or obese patients. We used the FLUID Trial database to evaluate associations between fluid infusion rate and outcomes in these patients. We compared children and youth who were overweight, obese, or normal weight, in regard to protocol adherence, mental status changes, time to DKA resolution, and electrolyte abnormalities. We investigated associations between outcomes and the amount of fluid received in these groups. Obese children and youth were more likely to receive fluids at rates slower than dictated by protocol. Overweight and obese children and youth in the fast fluid arms, who received fluids per the study protocol based on their measured weight, had similar rates of mental status changes or clinically apparent cerebral injury as those with normal weights. Risk of hypophosphatemia was increased in those receiving larger initial bolus volumes and reduced in those receiving higher rehydration rates. No other metabolic outcomes were associated with rehydration. Protocol adherence data in the FLUID Trial suggest that physicians are uncomfortable using weight-based fluid calculations for overweight or obese children. However, higher rates of fluid infusion were not associated with increased risk of mental status changes or cerebral injury, suggesting that physicians should not limit fluid resuscitation in obese children and youth with DKA.

THU326 Subcutaneous Insulin Aspart Every 4 Hours In the Treatment Of COVID-19 Patients With Diabetic Ketoacidosis: A Retrospective Study

Abstract Disclosure: D. Chiewchalermsri: None. C. Wanittansirichok: None. C. Sriphrapradang: None. SUBCUTANEOUS INSULIN ASPART EVERY 4 HOURS IN THE TREATMENT OF COVID-19 PATIENTS WITH DIABETIC KETOACIDOSIS: A RETROSPECTIVE STUDY Introduction: COVID-19 infection increases the risk of diabetic ketoacidosis (DKA). To limit the healthcare workers’ exposure when taking care of the COVID-19 patients, treatment of DKA with subcutaneous (SC) rapid-acting insulin analogs every 4 hours was suggested in many professional recommendations. However, the evidence to support this strategy is lacking. We aimed to report the efficacy and safety of SC insulin aspart every 4 hours in the management of DKA in COVID-19 patients. Methods: We retrospectively reviewed all confirmed COVID-19 patients aged &amp;gt;15 years who developed mild-moderate DKA between July 2020 and October 2021 in our institution. Insulin aspart was delivered 0.4 units/kg SC every 4 hours. When blood glucose (BG) decreased to &amp;lt;250 mg/dL, the dose of insulin aspart was reduced to 0.2 units/kg every 4 hours until resolution of DKA. SC Basal insulin 0.15-0.2 units/kg was also initiated at the time of DKA diagnosis. Result: A total of 7 patients had mean age of 67.43±13.19 years with body mass index of 25.49±3.42 kg/m2. Most was 71.4% of female and all had pre-existing type 2 diabetes mellitus. All patients received high-dose steroid for COVID-19 treatment. Initial biochemical parameters were BG of 449±157.3 mg/dL, hemoglobin A1c of 10.58±2.81%, pH of 7.34±0.07, beta-hydroxybutyrate of 4.0±1.51 mmol/L, and HCO3 of 15.5±2.17 mmol/L. Time to resolution of DKA were 12.7±5.82 hours. Conclusion: From our cohort, SC rapid-acting insulin administered every 4 hours could be applied in the selected COVID-19 patients with mild-moderate DKA. Presentation: Thursday, June 15, 2023

Newly diagnosed type 1 diabetes mellitus in a human immunodeficiency virus-infected patient with antiretroviral therapy-induced immune reconstitution inflammatory syndrome: a case report

BackgroundDiabetes that develops in human immunodeficiency virus (HIV)-infected patients who receive antiretroviral therapy (ART) is usually type 2 diabetes mellitus (T2DM); however, autoimmune diabetes, such as type 1 diabetes mellitus (T1DM) can also develop in this population. After treatment with ART, patients might experience clinical deterioration following an increase in the CD4 cell count, which is termed immune reconstitution inflammatory syndrome (IRIS). Here, we describe an HIV-infected patient on ART who developed T1DMat due to IRIS, highlighting the clinical complexity in diagnosis and treatment.Case presentationA 36-year-old man infected with HIV had a nadir CD4 cell count of 15.53/μL before medication, which increased to 429.09/μL after 9 months of regular ART. The fasting serum glucose at 9 months was between 96 mg/dL and 117 mg/dL. After 11 months of ART, the patient was admitted to hospital for diabetic ketoacidosis (DKA) and Graves’ disease (GD). Noninsulin antidiabetics (NIADs) were prescribed following the resolution of DKA. However, poor glycemic control was noted despite well-titrated NIADs. Further investigation demonstrated poor pancreatic beta cell function and elevated anti-glutamic acid decarboxylase (anti-GAD) and anti-tyrosine phosphatase-like insulinoma antigen 2 (anti-IA2) titers. According to the results, he was diagnosed with T1DM and received multiple daily injections(MDI) of insulin. The regimen of MDI was insulin degludec as basal insulin and insulin aspart as prandial insulin. After MDI therapy, his glycemic control was improved.ConclusionIn this case, T1DM was ascribed to IRIS. Although this phenomenon has been demonstrated in previous case reports, further study is necessary to realize the mechanism of this association. Therefore, we emphasize that when HIV-infected patients on ART experience an unstable blood glucose level and abnormal thyroid function, physicians should consider T1DM and GD associated with ART-induced IRIS to reduce the subsequent complications and more serious endocrine dysfunction.

Diabetic ketoacidosis induced Takotsubo cardiomyopathy: A case report

Takotsubo cardiomyopathy (TC) is a syndrome of transient regional wall motion abnormalities of the left ventricle causing an apical ballooning pattern. This condition can be triggered by intense emotional or physical stress. In the past, many case reports showed cases of diabetic ketoacidosis induced Takotsubo cardiomyopathy who presented with initial ST segment elevation ECG at the present to the hospital simultaneously with the ongoing stress. In this paper, we report a case of Takotsubo cardiomyopathy whose ST segment changed 2 days after the resolution of diabetic ketoacidosis.

What are we waiting for? A review of early basal insulin therapy in diabetic ketoacidosis management

Diabetic ketoacidosis (DKA) remains a significant challenge for healthcare systems due to prolonged lengths of stay and rising costs. The current American Diabetes Association (ADA) guidelines recommend starting basal insulin after resolution of DKA. However, these guidelines have not been updated since 2009, which can potentially limit optimal care. Meanwhile, the Joint British Society guidelines on DKA management, which were more recently updated in March 2023, do advocate for early administration of basal insulin in their treatment algorithm. This article assesses the rationale and literature associated with the recommendation for early basal insulin administration in the management of DKA. Benefits of early basal insulin in this cohort appears to be associated with less rebound hyperglycemia, reduction in time to DKA resolution, reduced intravenous insulin requirements, and reduced length of stay without associated increases in hypoglycemic or hypokalemic events.

Balanced crystalloids (RInger’s lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a protocol for a pilot randomized controlled trial

BackgroundCurrent guidelines for diabetic ketoacidosis (DKA) recommend treatment with normal saline (NS). However, NS, with its high chloride concentrations, may worsen acidosis and contribute to a hyperchloremic metabolic acidosis. Alternatives to NS are balanced crystalloids (e.g. Ringer’s Lactate [RL]) which have chloride concentrations similar to human plasma; therefore, treatment with balanced crystalloids may lead to faster DKA resolution. A recent systematic review and meta-analysis by Catahay et al. (2022) demonstrated the need for more blinded, high-quality trials comparing NS versus RL in the treatment of DKA.MethodsWe describe a protocol for BRISK-ED (Balanced crystalloids [RInger’s lactate] versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department). Our study is a single-centre, triple-blind, pilot randomized controlled trial (RCT) of adults (≥ 18 years) with DKA presenting to an academic tertiary care ED in London, Canada.Patients with clinical suspicion for DKA will be screened and those found to not meet DKA criteria or have euglycemic DKA will be excluded. We will aim to recruit 52 patients with DKA and will randomize them 1:1 to receive intravenous RL or NS.The primary feasibility outcome will be recruitment rate, and the primary efficacy outcome will be time elapsed from ED presentation to DKA resolution. Secondary outcomes include time to insulin infusion discontinuation, intensive care unit admission, in-hospital death, and major adverse kidney events within 30 days, defined as a composite of: i) death, ii) new renal replacement therapy, or iii) final serum creatinine ≥ 200% baseline at the earliest of hospital discharge or 30 days after ED presentation. Patients, clinicians, and outcome assessors will be blinded to allocation group. We will follow an intention-to-treat analysis. Gehan-Wilcoxon, Mann–Whitney U, or chi-square tests will be used to compare groups as appropriate.DiscussionThe results of this pilot study will inform the design and feasibility of a full-scale, multicentre RCT to assess fluid choice in adult ED patients with DKA. If proven to demonstrate faster resolution of DKA, administration of balanced crystalloids may replace NS in diabetes treatment guidelines and improve patient and health systems outcomes.Trial registrationClinicalTrials.gov, Registration # NCT04926740; Registered June 15, 2021.

Meglumine Sodium Succinate in Diabetic Ketoacidosis

The most common agent used for infusion therapy in patients with diabetic ketoacidosis (DKA) is isotonic 0.9% sodium chloride solution. However, infusion of required volumes can result in development of iatrogenic complications — i. e., worsening of metabolic hyperchloremic acidosis in DKA patients with already altered acid-base balance. Balanced crystalloid solutions can be used as alternative to saline.Objective. To evaluate the feasibility of using meglumine sodium succinate (MSS) balanced crystalloid solution in DKA.Material and methods. We examined 2 groups of patients, 30 subjects each, with moderate and severe diabetic ketoacidosis admitted to anesthesiology and intensive care unit. Patients from both groups were administered with insulin and an infusion therapy was employed according to current clinical guidelines for the management of patients with complications of diabetes mellitus. In the comparison group, infusion therapy included 0.9% sodium chloride, 4% potassium chloride, and 5% dextrose. In the study group MSS intravenous drip infusions 10 ml/kg/daily were added to the infusion protocol. Volumes and infusion rates were comparable in both groups. The following indicators were evaluated: time to resolution and DKA resolution rates during thorough monitoring (first 48 hours of therapy), the time (in hours) before discontinuation of insulin infusion; the time to complete consciousness recovery (15 items on the Glasgow Coma scale); the duration (in hours) of stay in the intensive care unit (ICU), dynamics of blood electrolytes; parameters of acid-base balance; levels of glycemia and lactatemia.Results. All patients improved and were transferred from ICU, the mortality rate was 0%. Infusion of MSS shortened the time to DKA resolution (30.0 h [24.0 h; 36.0 h] in the study group, vs 44.5 h [36.5 h; 51.5 h] in the comparison group (P=0.001)); DKA resolution rates during 48 hours from initiation of therapy achieved 90.0% (27) in the study group, vs 66.7% (20) in the comparison group (P=0.060)); duration of intravenous insulin infusion was 32.0 h [24.5 h; 40.0 h] in the study group vs 48.0 h [40.0 h; 55.5 h] in the comparison group (P=0.001)); duration of ICU stay was 41.0 h [30.0 h; 48.0 h] in the study group, vs 56.0 h [50.0 h; 66.3 h] in the comparison group (P=0.001).Conclusion. Infusion of a balanced succinate-containing crystalloid solution improves the results of DKA treatment, as compared to traditional infusion of 0.9% sodium chloride.

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.

1365-P: Recurrent Diabetic Ketoacidosis—Patient Characteristics and Clinical Outcomes in Qatar

Background: Recurrent diabetic ketoacidosis (DKA) is associated with poor clinical outcomes. Objective: We aimed to examine patients’ characteristics and clinical outcomes for patients hospitalized with recurrent DKA in Qatar. Methods: The hospital database was interrogated for patients admitted with DKA to government hospitals in Qatar between 2015 to 2020. Precipitating cause, clinical characteristics, laboratory data, severity of DKA, complications, need for admission to the intensive care unit, length of hospital stay, time to resolution of DKA, and mortality rates were evaluated in patients with recurrent (&amp;gt;1 admission) compared to a single admission. Results: A total of 1612 episodes of DKA, of which 434 patients (26.9%) had recurrent DKA, were evaluated. Compared to patients who had a single admission for DKA, those with recurrent DKA were younger [35.0 (24.0-53.0) vs 39.0 (28.0-54.0) years, p&amp;lt;0.001], more likely to be females (50.6% vs 37.1%, p&amp;lt;0.001), more likely to have type 1 diabetes (47.9% vs. 33.4%, p&amp;lt;0.001), a longer duration of diabetes [12.0 (5.0-19.0 vs 5.0 (0.0-13.0) years, p&amp;lt;0.001], more likely to have severe DKA (48.6% vs 38%, p&amp;lt;0.001), with a shorter time to resolution of DKA [12.5 (9.0-24.0) vs 23.0 (10.0-33.0) hours, p&amp;lt;0.001]. There was no difference in the precipitating cause of DKA, need for admission to the intensive care unit, hospital stay or inpatient mortality. On multivariable logistic regression analysis, significant predictors of occurrence of recurrent DKA were younger age (OR, 0.96; 95% CI, 0.95-0.98; p= 0.0001), female gender (OR, 0.63; 95% CI, 0.46-0.85; p= 0.003) and longer duration of diabetes (OR, 1.07; 95% CI, 1.04-1.09, p= 0.0001). Conclusion: In this cohort study, recurrent DKA was associated with younger age, female predominance and longer duration of diabetes. However, hospital course and inpatient mortality rates did not differ from those with a single admission for DKA. Disclosure M.Eledrisi: None. I.Alabdulrazzak: None. H.M.Alkabbani: None. M.K.Aboawon: None. A.A.Ali: None. M.F.Elhaj: None. A.O.E.Ahmed: None. H.Alqahwachi: None. R.A.Malik: None.

Subcutaneous Insulin Versus Traditional Intravenous Insulin Infusion in Treatment of Mild to Moderate Diabetic Ketoacidosis

BackgroundIntravenous (IV) insulin infusions are the current standard of care for treatment of diabetic ketoacidosis (DKA). Subcutaneous (SQ) insulin, however, may also be a safe and effective alternative. ObjectiveThe purpose of this study was to compare patient-centered outcomes related to the treatment of mild to moderate DKA using two different protocols: an SQ insulin protocol and an IV insulin infusion protocol with an initial bolus (IVB) or without a bolus (IVNB). MethodsWe retrospectively conducted a multicenter cohort study evaluating SQ vs. IV insulin for the treatment of mild to moderate DKA. The primary outcome was time to DKA resolution. Secondary outcomes included time to glucose correction, hospital length of stay (LOS), intensive care unit LOS, hypoglycemia events, readmission rates, and IV insulin use. ResultsWithin the study time frame, 257 patients were included in the multivariate Cox proportional hazards regression analysis. There was no significant difference in the time to DKA resolution between the IVB (p = 0.603) or IVNB (p = 0.269) groups compared with the population who received SQ insulin only. Hospital LOS was significantly longer when comparing the SQ group with the IVNB group (p < 0.001), but not when comparing it with the IVB group (p = 0.259). The IV protocols had significantly more hypoglycemic events compared with the SQ protocol (IVB vs. SQ, p < 0.001; IVNB vs. SQ, p = 0.001). ConclusionsSQ insulin may be an effective alternative option for treating mild to moderate DKA with fewer hypoglycemic effects.

The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis.

Our aims were to determine whether anion gap normalization time (AGNT) correlates with risk factors related to the severity of diabetic ketoacidosis (DKA) in children, and to characterize AGNT as a criterion for DKA resolution in children admitted with moderate or severe disease. A ten-year retrospective cohort study of children admitted to the intensive care unit with DKA. We used a survival analysis approach to determine changes in serum glucose, bicarbonate, pH, and anion gap following admission. Using multivariate analysis, we examined associations between patients' demographic and laboratory characteristics with delayed normalization of the anion gap. A total of 95 patients were analyzed. The median AGNT was 8 h. Delayed AGNT (>8 h) correlated with pH < 7.1 and serum glucose >500 mg/dL. In multivariate analysis, glucose >500 mg/dL was associated with an increased risk for delayed AGNT, by 3.41 fold. Each 25 mg/dL elevation in glucose was associated with a 10% increment in risk for delayed AGNT. Median AGNT preceded median PICU discharge by 15 h (8 vs. 23 h). AGNT represents a return to normal glucose-based physiology and an improvement in dehydration. The correlation observed between delayed AGNT and markers of DKA severity supports the usefulness of AGNT for assessing DKA recovery.

Safety of an Initial Insulin Bolus in the Treatment of Diabetic Ketoacidosis.

Background Insulin is a mainstay of treatment in diabetic ketoacidosis (DKA) however controversy remains over the optimal dose and administration. An initial bolus dose of insulin prior to a continuous infusion is utilized despite a lack of data showing clinical benefit and potential for complications. Objective This study was designed to evaluate the safety and efficacy of an initial insulin bolus in the treatment of DKA. Methods A retrospective chart review of patients with DKA was conducted. Fifty-nine patients met inclusion for the bolus group and 108 in the no-bolus group. The primary outcome was a composite of interruption of insulin infusion, hypoglycemia (BG <70mg/dL), or hypokalemia (K+ <3.4 mEq/L) occurring within eight hours of starting insulin. Secondary outcomes included time to discontinuation of insulin infusion, as well as time to discharge from the ICU and the hospital. Results Baseline characteristics were similar between groups. The majority of patients were classified as having mild DKA. The primary outcome occurred significantly more frequently in the bolus group (45.8% vs 25%, P = .003) which was primarily driven by incidence of hypokalemia. Time to anion gap closure (6:39 vs 9:00, P = .063) was shorter with a bolus, although not significantly so. This finding carried forward to non-significant differences in time to stopping insulin infusion as well as ICU and hospital discharge. Conclusion An insulin bolus prior to initiation of an insulin infusion was associated with significantly more adverse effects early in therapy without a corresponding benefit in time to resolution of DKA.

A Comparison of Variable Versus Fixed Insulin Infusion Rate on Resolution of Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is a well-known, potentially fatal complication of diabetes. The American Diabetes Association hyperglycemic crises guidelines suggest the use of intravenous insulin in patients presenting with DKA, along with a recommended rate of glucose reduction of 50-75 mg/dL/h. However, no specific guidance is provided regarding how to best achieve this rate of glucose decline. Is there a difference in time to DKA resolution between a variable intravenous insulin infusion strategy and a fixed infusion strategy in the absence of an institutional protocol? Single-center, retrospective cohort study of DKA patient encounters in 2018. Insulin infusion strategy was considered to be variable if the infusion rate changed within the first 8 hours of therapy or was considered fixed if the rate remained unchanged for the same period. The primary outcome was time to resolution of DKA. Secondary outcomes were hospital length of stay, intensive care unit length of stay, hypoglycemia, mortality, and DKA recurrence. The median time to resolution of DKA was 9.3 hours in the variable infusion group compared with 7.8 hours in the fixed infusion group (HR, 0.82; 95% CI, 0.43-1.5, P = 0.5360). Severe hypoglycemia was observed in 13% of patients in the variable infusion group and in 50% of patients in the fixed infusion group ( P = 0.006). In this analysis, insulin infusion strategy (variable vs. fixed) was not associated with a significant difference in the time to resolution of DKA in the absence of an institutional protocol. The fixed infusion strategy was associated with a higher incidence of severe hypoglycemia.

Impact on Diabetic Ketoacidosis Resolution After Implementation of a 2-Bfag Fluid Order Set.

Diabetic ketoacidosis (DKA) is a serious acute complication of both type 1 and type 2 diabetes that requires prompt management. Limited data exist supporting the use of a 2-bag DKA protocol in adult patients across all levels of care. To evaluate the efficacy and safety of a 2-bag DKA protocol in comparison with a traditional DKA management strategy. Retrospective review of patients admitted with DKA between January 1, 2021, and February 28, 2022, at a single center. Patients were separated into 2 cohorts, traditional or 2-bag. The primary outcome was time to anion gap closure and/or beta-hydroxybutyrate normalization. Secondary outcomes include length of hospitalization, insulin infusion time, and hypoglycemic events. One hundred forty-three patients had a DKA order set initiated during their admission, 59 in the traditional cohort and 84 in the 2-bag cohort. Mean time to anion gap closure was shorter in the 2-bag cohort (12.7 vs 16.9 hours; P = 0.005) and beta-hydroxybutyrate normalization (15.6 vs 25.6 hours; P = 0.026). No difference in hospital length of stay (4 vs 6 days; P = 0.113), duration of insulin infusion (41.6 vs 40.6 hours; P = 0.455), or rates of hypoglycemia (6 vs 4; P = 0.872) was seen. Implementation of a 2-bag DKA protocol in the inpatient setting was associated with a shorter time to anion gap closure and beta-hydroxybutyrate normalization. These findings support the option of expansion of a 2-bag DKA protocol to adult patients across all levels of care irrespective of the admission diagnosis.