Moderate Diabetic Ketoacidosis Research Articles

Subcutaneous fast-acting insulin analogues ± long-acting insulin vs IV insulin infusion in DKA: updated meta-analysis of randomised trials.

Diabetic ketoacidosis (DKA) is often treated with intravenous regular insulin infusion (IVRII). Subcutaneous fast-acting insulin analogues (FAIAs); either alone or combined with subcutaneous long-acting insulin (LAI); might be useful to treat DKA. Our meta-analysis updated on their benefits and safety in DKA. We searched major electronic databases for randomised trials on subcutaneous FAIAs ± subcutaneous LAI vs IVRII in DKA. Primary outcomes were all-cause in-hospital mortality, time to resolution of DKA and hyperglycemia, in-hospital DKA recurrence and hospital readmission for DKA post-discharge. Secondary outcomes included resource utilisation and patient satisfaction. Safety outcomes were adverse events. Reviewers assessed risk of bias and quality of evidence using GRADE. We performed a priori subgroup and trial sequential analyses on primary outcomes. Seven trials enrolled 351 mainly adult patients (255/351) with mild to moderate DKA. No trials studied subcutaneous FAIA and subcutaneous LAI. Their risk of bias was high or unclear in several domains. No all-cause in-hospital mortality and DKA recurrence were reported. No trial investigated hospital readmission for DKA post-discharge. There was no difference in mean time to resolution of DKA (mean difference = -0.70, 95% CI -2.18 to 0.79 h, p = 0.36) or hyperglycemia [blood glucose < 250 mg/dL (13.9 mmol/L)] (mean difference = -0.17, 95% CI -1.10 to 0.76 h, p = 0.72) between subcutaneous FAIA and IVRII groups. There were largely no subgroup effects. Both groups had similar secondary outcomes. Hypoglycemia was the most common adverse event. Quality of evidence was low to very-low for all outcomes. The only possible trial sequential analysis for time to resolution of DKA was inconclusive. There was low- to very-low quality evidence that subcutaneous FAIA did not affect patient-centered outcomes in mainly adult patients with mild to moderate DKA compared to IVRII.

12469 Impact Of Covid-19 Infection On Diabetic Ketoacidosis Severity And Outcomes In Adult Population- A Retrospective Observational Study

Abstract Disclosure: E.M. Niedzialkowska: None. K. Childers: None. L. Qu: None. L. Misra: None. M.R. Brennan: Consulting Fee; Self; Insulet Corporation, Bayer, Inc., Novo Nordisk. Background: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM) that can be precipitated by SARS-CoV2 infection. We analyzed clinical and demographic characteristics of patients admitted with DKA to investigate if SARS-CoV2 infection affects DKA severity on admission and outcomes. Methods: We conducted a retrospective cohort study that included adult patients admitted with a diagnosis of DKA between March 1, 2020, and March 1, 2023. Patients' demographic data including age, sex, race, ethnicity, laboratory test results on admission, ICU admissions and length of hospital stay (LOS) were compared. Patient characteristics and outcomes of interest were stratified by COVID-19 test results and compared using the Kruskal-Wallis test for continuous variables and Fisher’s exact test for categorical variables. DKA severity was classified based on HCO3 values: mild 15-18 mEq/L, moderate 10-14 mEq/L, severe &amp;lt;10 mEq/L. Results: The study included 902 patients, of which 734 tested negative (COVID-) and 168 tested positive (COVID+) for SARS-CoV2. The mean age was significantly higher (54.09) in COVID-19+ group compared to COVID-19- group (48.25) (p&amp;lt;0.001). The cohort included 49.1% females, 51.7% Whites, 43.3% Blacks, 89.8% Non-Hispanic/Latino, 2.7% Hispanic/Latino. We did not find statistically significant differences in sex (p= 0.608), race (p =0.277), ethnicity (p=0.072) anion gap (p=0.783), glucose (p=0.140), hemoglobin a1c (ha1c) values on admission (p=0.876) and ICU admissions (p=0.266) between both groups. The majority (55.3%) of the patients presented with severe DKA, followed by moderate DKA in 26.6% and mild disease in 18.1% of patients without statistically significant differences between groups (p= 0.128). The mean LOS in COVID + group (11.94 days) was longer than COVID- (6.85) group (p&amp;lt;0.001). Mean venous pH was significantly lower in COVID-19- (7.14) compared to COVID+ (7.17) group (p= 0.016). Betahydroxybutyrate (BHB) levels on admission were higher in COVID- group (7.98 mmol/L, N 0.02-0.27 mmol/L) compared to COVID + (7.10mmol/L) cohort. Conclusion: Patients diagnosed with COVID-19 and DKA on admission did not present with more severe disease compared to patients that tested negative. COVID+ patients were older (54.09 vs 48.2) and had significantly longer LOS (11.94 vs 6.85 days). We did not identify statistically significant differences between race, ethnicity, sex, glucose, anion gap, Ha1c on admission and ICU admission rate. BHB levels on admission were higher in patients that tested negative. Interestingly, mean pH was higher in COVID-19 positive group possibly due to respiratory disorders. Presentation: 6/1/2024

Retrospective Outcomes Comparison by Treatment Location for Pediatric Mild and Moderate Diabetic Ketoacidosis.

Pediatric diabetic ketoacidosis (DKA) is often treated in a PICU, but nonsevere DKA may not necessitate PICU admission. At our institution, nonsevere DKA was treated on the floor until policy change shifted care to the PICU. We describe outcomes in pediatric mild to moderate DKA by treatment location. Patients aged 2 to 21 with mild to moderate DKA (pH <7.3 but >7.1), treated on the floor from January 1, 2018 to July 31, 2020 and PICU from August 1, 2020 to October 1, 2022 were included. We performed a single-center, retrospective cohort study; primary outcome was DKA duration (from emergency department diagnosis to resolution), secondary outcomes included hospital length of stay, and complication rates, based on treatment location. Seventy nine floor and 65 PICU encounters for mild to moderate pediatric DKA were analyzed. There were no differences in demographics, initial pH, or bicarbonate; PICU patients had more acute kidney injury on admission. Floor patients had a shorter DKA duration (10 hours [interquartile range 7-13] vs 11 hours [9-15]; P = .04), and a shorter median length of stay (median 43.5 hours [interquartile range 31-62] vs 49 hours [32-100]; P < .01). No patients had clinical signs of cerebral edema; other complications occurred at similar rates. PICU patients received significantly more intravenous electrolyte boluses, but there were no differences in dysrhythmia or electrolyte abnormalities on final serum chemistry. Our study did not find a clear benefit to admitting patients with mild to moderate DKA to the PICU instead of the hospital floor. Our findings suggest that some children with nonsevere DKA may be treated safely in a non-PICU setting.

The Effects of Subcutaneous Rapid-Acting Insulin Aspart in the Treatment of Mild and Moderate Diabetic Ketoacidosis in Children: A Prospective Study.

Background and objectives The traditional treatment approach to diabetic ketoacidosis (DKA) involves the replacement of fluid and electrolyte deficits and a continuous intravenous infusion of regular insulin. Several clinical trials supported the administration of subcutaneous rapid-acting insulin analogs in the management of uncomplicated DKA. This study aimed to determine the effects/safety of subcutaneous rapid-acting insulin aspart injections in treating uncomplicated mild and moderate DKA in children. Methods In this prospective study in 2022, 25 children with mild/or moderate DKA were enrolled. The main outcome measure was median time (hours) for the resolution of ketoacidosis. Data recorded were as follows: clinical characteristics, severity of ketoacidosis and dehydration, blood glucose, sodium, potassium, creatinine, urine ketones, hospitalization's duration, and complications. Based on the degree of dehydration, fluid deficit was replaced by sodium chloride 0.45%. Insulin aspart 0.15 units/kg subcutaneous injections were given every 2 hours in the hospital outside ICU. Blood glucose was measured hourly and blood gases every 2 hours. Ketoacidosis was considered resolved when the patient did not have nausea/vomiting, was conscious, and could eat, and blood glucose was <250 mg/dL, pH was >7.30, and/or HCO3 was >15 mmol/L. Results Of 25 DKA patients (mean age 11.06±3.89, range 4-17 years, 60% girls), 16 cases (64%) had established type 1 diabetes. Overall, 13 (52%) cases had mild ketoacidosis (average pH=7.25), and 12 (48%) cases had moderate ketoacidosis (average pH=7.15). The mean time to resolution of ketoacidosis was 11.24 hours. All but one patient met DKA recovery criteria without complications. Mild cases compared to moderate cases of DKA had a shorter duration to resolution of DKA (p = 0.04). Mean duration of hospitalization was 2.3 days. No electrolyte disturbances, hypoglycemia events, readmission or mortality, or other adverse effects were observed. Conclusion In children with mild and moderate DKA, subcutaneous rapid-acting insulin aspart administration was an effective, safe, and convenient treatment.

Epidemiology of type 1 diabetes mellitus in children and adolescents: A 50-year, single-center experience.

Global variations in epidemiology of type 1 diabetes mellitus (T1DM) exist. This study is designed to examine demographic and clinical features of T1DM over the past 3 decades as well as evolving trends in epidemiology over last 50 years. Clinical characteristics of 925 patients with T1DM over last 30 years (1990-2019) were evaluated and compared to previously published data of 477 patients diagnosed between 1969 and 1990 from one of the major referral centers for diabetes in Turkey. Mean age at diagnosis decreased from 9.5 ± 4.0 to 7.1 ± 3.6 years within the past 50 years (p < .001). Age at diagnosis peaked at 12-14 years between 1969 and 1990, then fell to 10-11.9 years between 1990 and 1999, and to 4-5.9 years between 2000-2009 and 2010-2019 (p = .005). Although the percentage of patients diagnosed <6 years of age is gradually increasing, the percentage between the ages of 6 and 11.9 years is decreasing, and the percentage diagnosed ≥12 years remained stable. A total of 47.5% of patients had ketoacidosis, 38.2% had ketosis, and 14.3% had only hyperglycemia. 23% of patients had severe diabetic ketoacidosis (DKA), whereas 42% had moderate. Over last 3 decades, there has been no change in frequency of ketoacidosis at presentation, but there has been significant decline in severity (p = .865, and p < .001, respectively). Although the frequency of patients with mild DKA increased over time, frequency of patients with moderate DKA decreased; however, no significant difference was observed among patients with severe ketoacidosis. DKA was more frequent and severe in patients <6 years of age (p = .005, and p < .001, respectively). Age at diagnosis shifted to younger ages in T1DM in the past 50 years. Half of patients had ketoacidosis at diagnosis and frequency of presentation with DKA did not decrease, but severity decreased slightly. Increase in prevalence of T1DM in the younger age group and the fact that half of patients present with DKA indicate that awareness should be increased in terms of early diagnosis and treatment.

Pilot Study on the Impact of Early Subcutaneous Basal Insulin Administration in Diabetic Ketoacidosis.

Purpose/Background: Recent studies have shown improved outcomes with the initiation of earlier subcutaneous (SQ) basal insulin. The purpose of this study was to examine the effects of early SQ basal insulin administration on hospital length of stay in patients with mild to moderate diabetic ketoacidosis (DKA). Methods: This was a retrospective, single-center study from a large community teaching hospital that included patients 18 years or older with mild to moderate DKA, identified using ICD-10 codes, who received intravenous (IV) insulin. Patients who received SQ basal insulin prior to a documented anion gap ≤12 mmol/L were considered to have received early SQ basal insulin and were compared to patients who received SQ basal insulin after closure of their anion gap (AG). The primary outcome was hospital length of stay. Secondary outcomes included intensive care unit length of stay, duration of IV insulin, time to anion gap closure, and incidences of rebound hyperglycemia. Safety outcomes included incidences of hypoglycemia, and hypokalemia. Results: Of 301 patients screened, 108 patients were included in the final analysis. Forty patients received early SQ basal insulin and 68 did not. Median hospital length of stay in the nonearly group was 71 h, compared to 62 h in the early group (P = .57). Secondary and safety outcomes were similar between groups. Conclusions: In this study, there was no statistically significant difference in length of stay in patients that received early SQ basal insulin. Larger trials are needed to determine the significance of earlier SQ basal insulin in DKA.

Gastric emptying during and following resolution of moderate diabetic ketoacidosis in type 1 diabetes: a case series

IntroductionTo use the ‘gold standard’ technique of scintigraphy to quantify gastric emptying (GE) as soon as practicable during an admission with diabetic ketoacidosis (DKA) and following its resolution at least...

Hot off the press: Subcutaneous insulin for mild to moderate diabetic ketoacidosis.

Hot off the press: Subcutaneous insulin for mild to moderate diabetic ketoacidosis.

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.

Diabetic Ketoacidosis After COVID-19 Vaccine in Patients with Type 1 Diabetes Mellitus.

The coronavirus disease 2019 (COVID-19) vaccine is one of the few vaccines that obtained emergency authorization to combat the fatal pandemic. Despite the fact that some available literature addressed its short-term side effects, there are still limitations on its effects on type 1 diabetes mellitus (T1DM). The aim of the present study was to assess the association between COVID-19 vaccination and diabetic ketoacidosis (DKA) among individuals with T1DM. Additionally, the study aimed to determine the effects of the vaccine on glucose control, variability, and risk of hypoglycemia. This retrospective study was conducted at King Fahad Specialist Hospital (KFSH) in Qassim Region, Saudi Arabia. Diabetic ketoacidosis cases admitted to the hospital within February 2020 and August 2022 were included in the study based on specific inclusion criteria. Finally, a total of 49 patients were included in statistical analyses. Out of the 62 patients admitted to the hospital, 49 met the diagnostic criteria for DKA and agreed to participate in the study. The majority of the remaining patients (n = 13) refused to participate, and only a few of them lacked complete documentation. Of the 49 patients who were included in the study, 46 cases had a history of T1DM; nevertheless, 3 patients were newly diagnosed with T1DM. Additionally, among these participants, 16 (32.7%), 19 (38.8%), and 14 (28.6%) patients had mild, moderate, and severe DKA, respectively. There were 27 male (55.1%) and 22 female (44.9%) patients. About 91% of the patients were vaccinated against COVID-19, 30.6% of whom were vaccinated within 29 days of being diagnosed with DKA. The pH and bicarbonate levels were observed to be significantly high among those who were diagnosed with DKA within 29 days of vaccination, with p-values of 0.031 and 0.037, respectively. Similarly, pH and random blood sugar (RBS) were observed to be significantly higher among the vaccinated patients than in the non-vaccinated subjects (P = 0.044 and P = 0.032, respectively). The study findings revealed that some of the DKA indicators were evident among the vaccinated patients. However, larger-scale and multi-center studies are recommended in order to have more conclusive evidence and generalize the findings.

Clinical profile of patients with diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome in Japan: a multicenter retrospective cohort study.

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. Their clinical profiles have not been fully investigated. A multicenter retrospective cohort study was conducted in 21 acute care hospitals in Japan. Patients included were adults aged 18 or older who had been hospitalized from January 1, 2012, to December 31, 2016 due to DKA or HHS. The data were extracted from patient medical records. A four-group comparison (mild DKA, moderate DKA, severe DKA, and HHS) was performed to evaluate outcomes. A total of 771 patients including 545 patients with DKA and 226 patients with HHS were identified during the study period. The major precipitating factors of disease episodes were poor medication compliance, infectious diseases, and excessive drinking of sugar-sweetened beverages. The median hospital stay was 16days [IQR 10-26days]. The intensive care unit (ICU) admission rate was 44.4% (mean) and the rate at each hospital ranged from 0 to 100%. The in-hospital mortality rate was 2.8% in patients with DKA and 7.1% in the HHS group. No significant difference in mortality was seen among the three DKA groups. The mortality rate of patients with DKA in Japan is similar to other studies, while that of HHS was lower. The ICU admission rate varied among institutions. There was no significant association between the severity of DKA and mortality in the study population. This study is registered in the UMIN clinical Trial Registration System (UMIN000025393, Registered 23th December 2016).

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.

A Clinical and Biochemical Comparative Study Of Diabetic Ketoacidosis (DKA) in Newly Diagnosed Vs Known Cases of Type 1 Diabetic Children

Objectives: We aimed to study the characterizing clinical and biochemical profiles of Diabetic Ketoacidosis (DKA) in children with newly diagnosed Type 1 Diabetes Mellitus (Type 1DM) compared to children with established diagnosis of Type 1DM presenting with DKA admitted to the pediatric intensive care unit of a large university hospital in the eastern region of Saudi Arabia. Methods: We retrospectively reviewed the medical records of 211 patients who were admitted to the pediatric intensive care unit with diabetic ketoacidosis between 2010 and 2019. The diagnosis of diabetic ketoacidosis was based on symptoms of polydipsia, polyurea, weight loss, vomiting, dehydration, abdominal pain, breathing problems, lethargy or coma, biochemical hyperglycemia (blood glucose level of >200 mg/dL), venous pH of <7.3, serum bicarbonate level of ≤15 mEq/L, and ketonemia (blood β -hydroxybutyrate concentration of ≥3 mM) or moderate or severe ketonuria (diagnosed as newly acquired type 1 diabetes). Results: The rate of newly diagnosed Type 1 DM with DKA was 41.7%, out of them who got severe and moderate diabetic ketoacidosis were 61.6% and 38.4%, respectively. We observed significantly increased heart and respiratory rates in patients newly diagnosed with diabetic ketoacidosis and in those with severe diabetic ketoacidosis (p<0.001) compared to known cases with Type 1DM presenting with DKA. We also identified significantly increased biochemical indices including HbA1c, random blood sugar, serum osmolality, blood urea nitrogen, creatinine, chloride, lactate, and anion gap in relation to severe diabetic ketoacidosis and newly diagnosed type 1 diabetes (p ≤ 0.05). Conclusions: We found that the clinical and biochemical profiles of patients with newly diagnosed Type 1 DM children were significantly affected compared to children who were known Type 1DM presenting with DKA.

Frequency, Clinical Characteristics and Predictors of Ketoacidosis at Diagnosis of Type One Diabetes Mellitus in Children and Adolescents from Jordan

Data regarding diabetic ketoacidosis (DKA) at diagnosis of type one diabetes (T1D) in developing countries are scarce. The aim of this study was to describe the frequency of DKA at the onset of T1D in children and adolescents in Jordan and to compare the clinical and biochemical characteristics between the group that presented with DKA and the group that did not. The records of 341 children and adolescents, less than sixteen years of age, who were diagnosed with T1D between 2015 and 2019 were evaluated retrospectively. Of all the children diagnosed with T1D, 108 (31.7%) presented with DKA. The majority had mild or moderate DKA (38% and 33.3% respectively). Higher paternal education levels were associated with a lower probability of presenting with DKA (p=0.043). A family history of T1D had a protective effect on the occurrence of DKA (Odds ratio=2.138; 95% confidence interval=1.167-3.917, p=0.014). Patients with celiac disease and higher HbA1c levels were more likely to experience recurrent episodes of DKA, (p=0.004 and 0.011, respectively). In Jordan, the rate of DKA at presentation of T1D remains high. Prevention campaigns are needed to increase diabetes awareness among the public and healthcare providers.

Is HbA1c an Indicator of Diabetic Ketoacidosis Severity in the Pediatric Population?

Glycosylated hemoglobin (HbA1c) reflects how well blood glucose is controlled and is one of the strongest predictors of chronic complications of diabetes mellitus. The degree of acidosis helps determine the severity of diabetic ketoacidosis (DKA) (mild: pH 7.2-7.3; moderate: pH 7.1-7.2; severe: pH <7.1) and guides the level of care and predicts outcome. Many studies have implicated that higher HbA1c levels lead to recurrent DKA. However, there is no description of the association of higher HbA1c with the severity of DKA. One hundred thirty-eight electronic medical records of patients aged 1 to 21 years admitted to the pediatric intensive care unit with DKA between 2011 and 2015 were analyzed. We excluded 50 patients because the HbA1c level was not available. Spearman correlation analyzed the data for 88 patients included in the study. The mean HbA1c was 13.3, with female patients having more admissions compared with male patients (58% vs 42%). The age group from 13 to 21 years accounted for 77.3% of the patients. The duration of type 1 diabetes mellitus did not affect the HbA1c level. Likewise, the blood glucose and serum creatinine level did not show a statistical correlation with blood pH levels. Mean HbA1c for mild, moderate, and severe DKA groups were 11.4%, 12.2%, and 14.8%, respectively. Blood pH and HbA1c returned a negative correlation (correlation coefficient, -0.557; P = 0.005). The HbA1c level correlated positively with the 3 groups of DKA (correlation coefficient, 0.595; P = 0.01). A higher A 1c was associated with more severe DKA.

Neutrophil-to-Lymphocyte Ratio Adds Valuable Information Regarding the Presence of DKA in Children with New-Onset T1DM.

Diabetic ketoacidosis (DKA) is an acute life-threatening complication occurring mainly at the onset of type 1 diabetes mellitus. The neutrophil-to-lymphocyte ratio (NLR), a marker for systemic inflammation, has recently generated increasing interest in many chronic diseases. The aim of this cross-sectional study was to determine the value of the neutrophil-to-lymphocyte ratio (NLR) in association with DKA severity across these cases. A total of 155 children with new-onset type 1 DM from one large center were included in the study. Total and differential leukocyte counts were measured upon admission and calculation of the NLR was performed. Patients were classified into four groups: without DKA, mild, moderate, and severe DKA at disease onset. Total WBCs, neutrophils, and monocytes increased with DKA severity (p-value < 0.005), while eosinophiles displayed an inverse relationship (p-value < 0.001). Median NLR scores increased from those without ketoacidosis (1.11) to mild (1.58), moderate (3.71), and severe (5.77) ketoacidosis groups. The statistical threshold value of the NLR in predicting DKA was 1.84, with a sensitivity of 80.2% and a specificity of 80%. Study findings indicate that a higher NLR score adds valuable information regarding the presence of DKA in children with new-onset T1DM.

600: RETROSPECTIVE REVIEW OF OUTCOMES IN PEDIATRIC DKA: EARLY VERSUS LATE LONG-ACTING INSULIN

Introduction: In patients with diabetic ketoacidosis (DKA), the American Diabetes Association guidelines support administering long-acting insulin (LAI) at the time of conversion from IV insulin to subcutaneous rapid acting insulin (RAI). Challenges with LAI timing in children may complicate this transition, and LAI may be administered earlier in the DKA course at some institutions. Limited evidence currently exists assessing the value of this early LAI administration while the patients are still in DKA. The purpose of this study was to assess the benefit and safety of early LAI in pediatric DKA. Methods: This single-center retrospective cohort study included patients < 21 years old admitted to the PICU in DKA on an IV insulin drip. Patients meeting inclusion criteria were divided into two groups: early LAI (administered >4 hours prior to conversion to RAI) and late LAI (administered within 2 hours of RAI). Each group was subdivided into DKA severity (moderate vs severe) and new onset vs known diabetes. The primary outcome of the study was to compare the time to DKA resolution, and secondary outcomes evaluated the total IV insulin doses received, and incidence of adverse effects and complications: hypoglycemia, hypokalemia, cerebral edema, and recurrence of DKA. Results: A total of 372 encounters were included in the preliminary assessment (224 in early LAI and 148 in late LAI groups). Baseline characteristics were similar between both groups. The time to DKA resolution was significantly longer (13 vs. 9.6 hours, p< 0.0001) and total dose of IV insulin significantly higher (65.7 vs. 44 units, p=0.0018) in the early LAI group. Rates of mild hypoglycemia and hypokalemia were significantly higher in the early LAI groups (33.5% vs. 21.6%, p=0.0134 and 42.4% vs. 14.2%, p< 0.0001, respectively). The trends in longer duration of DKA and rates of these adverse effects for the early LAI were also seen in the subgroups of new onset patients and with both moderate vs severe DKA. No differences were observed with severe hypoglycemia or hypokalemia, rates of cerebral edema or recurrence of DKA. Conclusions: Use of early LAI in pediatric DKA demonstrated no reduction in the time to resolution of DKA or total IV insulin dose regardless of severity of presentation, and increased risk of mild hypoglycemia and hypokalemia.

Treatment of diabetic ketoacidosis with subcutaneous regular insulin in a non-ICU setting is effective and economical: A single-center experience

Background: The mainstay of treatment for diabetic ketoacidosis (DKA) is the correction of dehydration and hyperglycemia with intravenous fluids and intravenous insulin (IVI). Subcutaneous insulin (SCI) has been tried in a few centers in patients with DKA if the blood pH is &gt;7. In general, IVI is preferred over SCI or intramuscular insulin as its onset is rapid and the dose can be titrated based on patient’s varying blood glucose (BG) levels. However, IVI is associated with higher cost of hospitalizations and resource requirements. Thus, SCI could be an alternative to IVI infusion for DKA to reduce these costs and distress, in children during times of resource constraint such as the COVID-19 pandemic and in other resource-limited settings. Objective: The objective of the study was to compare the cost and efficacy of SCI therapy versus IVI infusion in the treatment of DKA. Materials and methods: A retrospective and cohort study was conducted among children aged 1–15 years admitted with DKA from 2013 to 2014 and treated with IVI and in 2017 treated with SCI at a tertiary hospital. One cohort was treated with IV infusion of regular insulin in intensive care units (ICU) and another cohort was treated with SC regular insulin in pediatric general wards. The main outcomes measured were the overall cost of hospitalization and hours to improvement in the child’s health. The data were analyzed with independent samples t-test with SPSS software. Results: Forty-eight patients admitted with 50 episodes of DKA were analyzed. Baseline characteristics of the two groups were similar in age, sex, BG, serum sodium, and HbA1C levels. The proportion of girls to boys was 13:8 (IV insulin group) and 20:9 (SC insulin group); the daily dose of insulin on day 1 of treatment was 1.2:1 unit/kg/day in IVI: SCI groups. The lowest recorded pH was 6.822 (range 6.822–7.154) and 6.831(range 6.831–7.292) in the IVI and SCI groups. The mean pH was 7.00 ± 0.10 and 7.1 ± 0.12, respectively, in IVI and SCI groups (P = 0.02). Episodes of DKA treated with IVI and SCI groups were 21 and 29, respectively. 23% of patients had severe DKA, 52% had moderate DKA, and 25% had mild DKA. The mean time for improvement in the IVI group was 34.95 ± 14.05 h and 17.23 ± 9.85 h in the SCI group (P = 0.001), respectively. The average cost of hospitalization was Rs. 53712 ± 18813 for IVI therapy and Rs. 14369 ± 5768 for SCI (P = 0.000). There were no major complications in the SCI group compared to the IVI group. Conclusion: DKA was managed effectively in general wards with SCI therapy with pH not being a limiting factor. Earlier studies have used SCI only in patients with a pH of &gt;7. Therapy with SCI was cost-effective and would be useful in resource-poor settings.

IMPROVING THE UTILIZATION OF RESOURCES: CAN MILD TO MODERATE DIABETIC KETOACIDOSIS PATIENTS BE TREATED WITH SUBCUTANEOUS INSULIN ON THE MEDICAL WARD?

IMPROVING THE UTILIZATION OF RESOURCES: CAN MILD TO MODERATE DIABETIC KETOACIDOSIS PATIENTS BE TREATED WITH SUBCUTANEOUS INSULIN ON THE MEDICAL WARD?

Diabetic Ketoacidosis and its Severity Predictors in Type 1 Diabetic Children; A 10-year Experience of A Teaching Hospital in Saudi Arabia.

OBJECTIVE: Our objective was to determine the trend and precipitating factors of the severity of diabetic ketoacidosis (DKA) in the population admitted to the Pediatric Intensive Care Unit (PICU) in a large teaching hospital in the Eastern region of Saudi Arabia. METHODS: We conducted a retrospective, analytical study at King Fahad Hospital, Imam Abdulrahman Bin Faisal University, Alkhobar, Saudi Arabia. We retrieved the complete medical records of 2234 children who were admitted to the PICU during the 10-year period of 2010 through 2019. The children included those with polydipsia, polyurea, abdominal pain, vomiting, dehydration, and weight loss, as well as breathing disturbances due to acidosis and CNS issues such as lethargy or coma and elevated blood glucose level, > 200 mg/dL [> 11.1 mmol/L], venous pH 7.3, serum total CO2 15 mmol/L, and blood- hydroxybutyrate concentration 3 mmol/L or moderate or severe ketonuria. RESULTS: Out of 2234 PICU admissions, 211 (9.4%) were diagnosed with DKA. A persistent increase in the rate of DKA ended up at 14.1% in 2019 (p = .005). The incidence of DKA was 88/2234 (3.93%). The severity of DKA was as follows: 130 (61.6%) had severe and 81 (38.4%) had moderate DKA. Excessive sweet intake without adding insulin in 83 (39.3%) patients and unhealthy lifestyles (35.1%) were the best predictors of severe DKA (p = .001). CONCLUSION: Over a 10-year period, the DKA pattern was persistently rising and slightly falling, which ended up at the significantly highest rate of 14.1% in 2019. URTI, pneumonia, unhealthy lifestyle, and excess sweet intake were significant precipitating factors associated with severe DKA.