Diabetic Ketoacidosis Patients Research Articles

First onset of diabetic ketoacidosis in teenagers with COVID-19: a case report from a limited health care setting

Background: Diabetic ketoacidosis (DKA) has been well-known as the main complication that is a potentially fatal emergency in some teenagers with type 1 diabetes mellitus (DM). Although children with diabetes are not at high risk for severe COVID-19 infection, it can hypothetically lead to type 1 DM and severe DKA. The aim of this article is to briefly discuss a case of a teenager with DKA and COVID-19. Case: A 13 years old girl came in with abdominal pain, nausea, vomiting and dyspnea. She was alert but weak. Her blood pressure was 100/70 mmHg with 120 pulses and 35 breaths per minute. Oxygen saturation was at 99%. History of previous illness was denied. She was treated using a dyspepsia algorithm while waiting for the laboratory result. Later on, the test showed conditions of hyperglycemia, severe acidosis, ketonuria and a positive rapid COVID–19 antibody test. Hence, a diagnosis of DKA with probable COVID–19 was made and PCR for confirmation of COVID-19 diagnosis was scheduled. Oxygen support, rehydration, and insulin therapy were also given with a precautionary condition of possible COVID–19. In minutes, she developed respiratory distress that led her to be intubated and put on a ventilator. Due to a lack of facilities, a referral to a higher-level hospital was needed. However, since the referral process for probable COVID-19 patients required a long preparation, the patient died during the process. Conclusion: Besides early diagnosis and prompt treatment, a well-coordinated referral system is crucial in managing DKA patients with possible COVID–19.

Diabetic Ketoacidosis Was Associated with High Morbidity and Mortality in Hospitalized Patients with COVID-19 in the NYC Public Health System

Background: COVID-19 has been associated with a higher risk of death in patients with diabetes mellitus (DM). However, there is a dearth of data regarding the effects of diabetic ketoacidosis (DKA) in these patients. We explored the in-hospital outcomes of patients who presented with COVID-19 and DKA. Methods: A propensity score-matched observational retrospective cohort study was conducted in hospitalized patients with COVID-19 in the public healthcare system of New York City from 1 March 2020 to 31 October 2020. Patients were matched, and a subgroup analysis of patients with DKA and COVID-19 and patients without COVID-19 was conducted. Results: 13,333 (16.0%) patients with COVID-19 and 70,005 (84.0%) without COVID-19 were included in the analysis. The in-hospital mortality rate was seven-fold in patients with DKA and COVID-19 compared to patients with COVID-19 and without DKA (80 (36.5%) vs. 11 (5.4%), p < 0.001). Patients with COVID-19 and DKA had a two-fold higher likelihood for in-hospital death (OR: 1.95; 95% CI: 1.41–2.70; p < 0.001) after adjusting for multiple variables. Conclusions: DKA was associated with significantly higher in-hospital mortality in hospitalized patients with COVID-19.

The Impact of Inflammatory Bowel Disease on Mortality and Other Outcomes of Hospitalized Patients With Diabetic Ketoacidosis: An Observational Study of the United States National Inpatient Sample.

BackgroundRecent studies have shown an increased risk of diabetes mellitus in patients with Inflammatory bowel disease. However, the impact of IBD on outcomes of patients with diabetic ketoacidosis remains unknown.MethodsThis is an observational analysis of the National Inpatient Sample Database. The authors identified patients with a diagnosis of diabetic ketoacidosis and inflammatory bowel diseases. Outcomes studied were differences in risk of mortality, in-hospital outcomes and healthcare resources utilization. Multivariate logistic analysis was performed and results were adjusted for patient and hospital characteristics and comorbidities.ResultsNo significant difference in mortality was observed in the DKA-IBD group when compared to the DKA-only group (aOR 0.55, p = 0.560). Similarly, inflammatory bowel disease had no impact on risk of sepsis (aOR 1.06, p = 0.742), acute kidney injury (aOR 1.08, p = 0.389), acute coronary syndrome (aOR 0.70, p = 0.397), ischemic stroke (aOR 1.53, p = 0.094), acute respiratory failure (aOR 1.00, p = 0.987), invasive mechanical ventilation (aOR 0.54, p = 0.225), deep vein thrombosis (aOR 1.68, p = 0.275), pulmonary embolism (aOR 2.16, p = 0.279) or cardiac arrest (aOR 1.35, p = 0.672) in diabetic ketoacidosis patients. The study group had a significant increase in length of stay (adjusted mean difference 0.63, p = 0.002) and charge of care (adjusted mean difference 3,950$, p = 0.026).ConclusionInflammatory bowel disease is not associated with risk difference in mortality or morbidity in admitted patients with diabetic ketoacidosis, however, it does contribute to increased healthcare resources utilization.

Treatment Considerations and Pharmacist Collaborative Care in Diabetic Ketoacidosis Management

Diabetic ketoacidosis (DKA) is a medical emergency caused by the lack of insulin. Metabolic acidosis, hyperglycemia, and ketoacidosis are its defining features. Insulin deficiency can cause DKA either in the presence or absence of a triggering event causing a chain of pathophysiological changes. Normalizing volume status, hyperglycemia, electrolytes, and ketoacidosis are the objectives of DKA treatment. While hospital pharmacists are involved in managing DKA, community or ambulatory care pharmacists can help to prevent DKA. Depending on the particular field of practice, a pharmacist’s engagement in DKA may involve a number of factors. Inpatient pharmacists are in a good position to help with the acute care of DKA. Because they can recognize patients who are at risk for DKA due to factors including medication nonadherence or insulin pump failure, pharmacists in the community or ambulatory-care environment play a crucial role in its prevention. When a patient finds it challenging to navigate prescription plan coverage or a lack of coverage, community pharmacists can help them obtain insulin. Regardless of the professional environment, patient education is essential. Every pharmacist has the ability to give DKA patients thorough medication education that emphasizes the value of adhering to their drug schedule, addresses any obstacles that may occur, and teaches patients how to correctly monitor their blood glucose levels. Studies showed that pharmacists’ medication counseling and treatment monitoring could improve adherence to insulin medication. The aim of this review is to provide evidence that pharmacists can contribute to optimizing medication adherence and decrease the incidence of DKA.

Frequency of Complications in Admitted Patients of Diabetic Ketoacidosis

Objective: To determine the frequency of different complications in admitted patients of diabetic ketoacidosis (DKA). Study Design: A cross-sectional study. Place and Duration: Diabetic ward of National Institute of Child Health (NICH), Karachi Pakistan from 1st November 2020 to 31st October 2021. Methodology: A total of 253 children of either gender aged 1 to 15 years admitting with DKA and duration of diabetes mellitus ≥3 years were included. All patients were subjected to detailed history and clinical examination for DKA and its complication like hypoglycaemia, hypokalaemia, hyponatraemia, hypocalemia, hyperkalaemia. Resutls: In a total of 253 children admitted with DKA, 123 (48.6%) were girls and 130 (51.4%) boys. Mean age of patients was 6.11 ± 2.87 years, mean BMI was 20.9± 4.7 kg/m2, while mean duration of diabetes mellitus was 3.5± 1.2 years. Mean plasma glucose was 22.5±6.0 mmol/L (405±108mg/dl), mean HbA1c 10.2±2.1% while mean pH was 6.9±0.4. In a total of 253 patients with DKA, hypoglycemia was noted in 47(18.6%), hypokalemia 17 (6.7%), hyponatremia 22 (8.7%), hypocalcaemia 11 (4.35%) while hyperkalaemia was observed in 9 (3.56%) patients. Conclusion: Most of the patients admitted with DKA were aged <10 years who developed complications. Hypoglycemia was the most common complication of DKA while hyponatremia the 2nd most frequent complication observed in DKA patients. Electrolytes should be investigated and managed timely to avoid unwanted outcomes among patients admitted with DKA. Keywords: Complications, diabetic ketoacidosis, diabetes mellitus, children.

Systemic Infection Predictive Value of Procalcitonin to Lactic Acid Ratio in Diabetes Ketoacidosis Patients.

IntroductionEarly detection of bacterial infections associated with adequate antibiotic treatment is key to improving diabetic ketoacidosis (DKA) outcomes. Our study aimed to investigate the different sepsis markers (including procalcitonin to lactic acid ratio, PLR) to diagnose bacterial infection in patients with DKA within one hour after admission.MethodsA total of 165 patients diagnosed with DKA were enrolled between July 2014 and July 2018 and divided into an infection group (N =62) and a non-infection group (N=103) based on the positive aetiological tests such as blood culture, sputum culture, urine culture, or definite focus of pulmonary, soft tissue, kidney, etc.ResultsOur findings suggest the following: 1) leucocytes (threshold above 10×109 /L) and PLR (threshold above 0.438) within one hour after admission can help to identify patients with infection in the context of DKA. 2) A subgroup analysis demonstrated that PLR also has a high diagnostic efficacy for infection in patients with DKA, regardless of the type of diabetes.ConclusionThis study concludes that leucocyte count (threshold > 10×109/L) and PLR (threshold above 0.438) show a diagnostic value to help distinguish DKA patients with infection. By combining these two markers, the reduction of antibiotic misuse may be possible.

1162-P: Clinical Characteristics and Outcomes in Patients Hospitalized with Diabetic Ketoacidosis

Background: Diabetic ketoacidosis (DKA) is an acute complication of uncontrolled diabetes that is associated with increased morbidity and mortality. Objective: We aimed to examine clinical characteristics and care outcomes for patients hospitalized for DKA. Methods: We reviewed the hospital database for patients who were admitted with DKA from 2015 to 2020 in government hospitals in Qatar. Clinical characteristics, laboratory data, the 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 type 1 diabetes (T1DM) compared to those with type 2 diabetes (T2DM) . Results: A total of 1613 episodes of DKA in 1330 patients (39.3% with T1DM and 60.7% with T2DM) were evaluated. Non-adherence to therapy was the commonest cause (40.5%) of DKA in patients with T1DM, while infection was the commonest cause (32.9%) in those with T2DM. There was no difference in the severity of DKA, mean serum glucose, mean serum sodium, and arterial pH on presentation in both groups of patients. Both groups had poorly controlled glucose (mean HbA1c of 10.1% and 10.5% in T1DM and T2DM groups respectively) . There was no difference in the time to resolution of DKA (18 hours in the T1DM group and 20 hours in the T2DM group) . Patients with T2DM had higher rates of admission to the intensive care unit (39.1% vs. 26.9% for T1DM, p<0.001) , longer hospital stay (mean 5 days vs. 2 days in the T1DM group, p<0.001) , while patients with T1DM had higher rates of recurrent DKA (35.6% vs. 21.2% in the T2DM group, p<0.001) . Mortality rates were significantly higher in patients with T2DM compared to those with T1DM patients (7.6% vs. 0.95%, respectively, p<0.001) . Conclusion: In this cohort study, poorly controlled glucose was prevalent among patients admitted with DKA. Despite higher rates of recurrent DKA in patients with T1DM, those with T2DM had more complicated hospital course and higher mortality. Disclosure M.Eledrisi: None. S.A.Beshyah: None. M.K.Aboawon: None. H.M.Alkabbani: None. A.A.Ali: None. I.Alabdulrazzak: None. M.Elhaj: None. A.O.E.Ahmed: None. H.Alqahwachi: None. J.Daghfal: None.

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

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

Risk Factors and Laboratory Findings Associated With Diabetic Ketoacidosis in Hospitalized Pediatric Patients.

Background: Diabetic ketoacidosis (DKA), the most serious and acute complication of type 1 diabetes, has an incidence of 6%-8% among known pediatric type 1 diabetes patients, although risk factors associated with severe DKA in the pediatric population are poorly understood [1].Method: A single-institution, retrospective chart analysis of pediatric DKA patients admitted to our pediatric intensive care unit (PICU) was conducted in South Alabama between October 2017 and April 2021. Laboratory findings were obtained from venous samples collected from the patients on admission.Results: Of 429 admissions, 256 unique patients were admitted with DKA to PICU during the 3.5-year period; 55.9% of them were males. The median (IQR) age of the patients was 12 (10-15) years, and their median HbA1c level was 11.02 (10%-12%), which was similar to Medicaid and private insurance statistics (11.1 [9.87-12.2] vs 11 [9.65-12], p = 0.4). Serum pH on presentation was 7.17 (7.08-7.25), and serum bicarbonate was 10 (7-14) mmol/L. White blood cell (WBC) count, platelet count, and mean platelet volume (MPV) had a negative correlation with serum pH (r = -0.52, p < 0.001, r = -0.25, p = 0.01 and r = -0.11, p = 0.03, respectively). The blood urea nitrogen (BUN):creatinine ratio had a positive correlation with serum pH (r = 0.16, p < 0.001). Twenty-nine admissions (6.8%) with a median age of 16 (13-17) years required imaging for altered mental status, and none of these patients were diagnosed with cerebral edema.Conclusion: DKA is associated with noncompliance among pediatric patients, irrespective of their type of insurance. Markers of oxidative stress (WBC, platelets, and MPV) were associated with increased severity of DKA. The BUN:creatinine ratio may not provide accurate hydration status among DKA patients. Clinicians need to have a lower threshold for head imaging among younger patients.

The Influence of Obesity Hypoventilation Syndrome on the Outcomes of Patients With Diabetic Ketoacidosis.

Purpose: The effect of comorbid obesity hypoventilation syndrome (OHS) on hospitalized patients with diabetic ketoacidosis (DKA) has not been studied so far. This study elucidates the outcomes of DKA patients with OHS compared to those without OHS.Methods: Patients above 18 years of age were included in the study. The National Inpatient Sample (NIS) database of 2017 and 2018 was used and data were extracted using the International Classification of Diseases, Tenth Revision (ICD-10) codes; OHS ICD-10 code being “E66.2” and DKA ICD-10 codes being “E08.1, E09.1, E10.1, E11.1, and E13.1.” The comorbid medical conditions were also identified using the ICD-10 codes. Logistic regression analysis was performed to examine the impact of OHS on in-hospital outcomes of DKA patients.Results: OHS was prevalent in 0.61% of the general population, as per the NIS database in the years 2017 and 2018. Primary outcomes of the study were in-hospital mortality, whereas secondary outcomes included acute kidney failure, the requirement for invasive mechanical ventilation, length of stay, and cost of hospitalization. OHS in DKA patients was associated with increased mortality (odds ratio (OR): 4.35 (2.63-7.20), p < 0.00001; adjusted OR (aOR): 1.79 (1.01-3.15), p < 0.044), acute kidney failure (OR: 2.44 (1.79-3.33), p < 0.00001; aOR: 1.43 (1.03-2.00), p < 0.031), invasive mechanical ventilation (OR: 4.17 (2.90-5.98), p < 0.00001; aOR: 1.62 (1.08-2.41), p < 0.017), increased length of stay (10.02 ± 12.42 vs. 4.70 ± 6.31, p < 0.00001), and cost of care (132314 ± 197111.8 vs. 54245.06 ± 98079.89, p < 0.00001). All-cause mortality of patients with DKA and OHS using the Cox proportional hazards ratio was 1.70 (1.02-2.84, p < 0.024) after adjusting for age, race, sex, smoking, obesity, and comorbidities such as heart failure, hypertension, chronic obstructive pulmonary disease, chronic ischemic heart disease, chronic kidney disease, liver disease, and cerebral infarction.Conclusion: OHS is an independent risk factor for mortality in DKA, irrespective of the degree of obesity. Further prospective studies are recommended to study the effects of different treatment modalities of OHS such as identification of the need for early non-invasive ventilation or for early invasive mechanical ventilation to improve outcomes in DKA patients.

Diabetic Ketoacidosis Precipitated by COVID-19: A Case Report

Introduction: Diabetic emergencies such as diabetic ketoacidosis (DKA) are life-threatening complications, often precipitated by infections or illnesses such as COVID-19. Case presentation: A 55-year-old African American female presented to their primary care physician, complaining of fatigue, dehydration, decreased appetite, hypersomnia, and sudden weight loss, and a past medical history of Type 2 diabetes. They had a glucose level of &gt;15 mmol/L and ketone level of &gt;16 mmol/L; they were immediately sent to the emergency department for assessment of DKA. There, the patient tested positive for COVID-19. They had a glucose level of 361 mg/dL, a pH of 7.11, a bicarbonate level of 10 mEq/L, a sodium level of 125 mEq/L, a potassium level of 3.9 mEq/L, a chloride level of 95 mEq/L, an anion gap of 20, and a positive ketone level. Over the next few days, the patient’s condition got worse; their chest CT scan showed ground-glass opacities with consolidations in the middle and inferior lobes of the lungs bilaterally, along with interlobular septal thickening, which are consistent with an atypical infection, respiratory distress, and pneumonia. The patient was on intravenous fluids, insulin therapy and empirical antibiotics for the next few weeks, and eventually recovered. Discussion: Factors precipitating DKA in patients with diabetes in the setting of COVID-19are: the increased secretions of stress hormones that counter the effects of insulin and increase blood glucose levels, and the ways in which severe acute respiratory syndrome coronavirus 2 interacts with human cells, leading to pancreatic islet cell damage. Conclusion: Diabetes and COVID-19 intensify each other’s complications in patients diagnosed with both.

Sodium-glucose cotransporter 2 inhibitor associated diabetic ketoacidosis in chronic heart failure: a case series

Abstract Funding Acknowledgements Type of funding sources: None. Background The sodium-glucose cotransporter 2 inhibitor (SGLT2i) medications have proven mortality and morbidity benefit for patients with type 2 diabetes mellitus (T2DM) and chronic heart failure (HF) over the previous decade leading to a rapid expansion of societal guideline recommendations and US FDA indications. With this rapid expansion of SGLT2i indications and prescribing, it is essential that we understand the safety and adverse effects of this drug class. Diabetic ketoacidosis (DKA) is a life-threatening adverse effect of the SGLT2i that has been described in post-marketing reports, prompting an FDA warning. The clinical characteristics of patients with T2DM and HF who develop SGLT2i associated DKA are lacking. Purpose To describe the clinical characteristics of patients with T2DM and chronic HF prescribed SGLT2i who develop DKA. Methods Data was collected retrospectively with Penn State Health TriNetX Local, a web-based tool for healthcare system research population queries, between January 1, 2013-December 31, 2020. Patients with T2DM and chronic HF who were prescribed empagliflozin, canagliflozin or dapagliflozin and subsequently developed DKA were eligible for inclusion. Patients with type 1 diabetes mellitus were excluded. Patient health records were reviewed to confirm SGLT2i use at the time of DKA hospitalization. Baseline characteristics, clinical features and outcome data of hospitalized patients were collected. Results Four unique patient records were identified. Mean age was 59.8 years, BMI 30.5 kg/m2, HbA1c 10.6%. Two patients had baseline heart failure mid-range ejection fraction and two patients had heart failure preserved ejection fraction. All patients were baseline NYHA class II, ACC/AHA stage C. Three patients were on a baseline diuretic, two were on ACE/ARB, two were on beta blocker, three were on metformin, two were on pioglitazone and none were on insulin. Two patients were on baseline empagliflozin 10 mg daily and two were on canagliflozin 100 mg daily. Two patients were on SGLT2i for less than 1 month prior to presentation. Three patients presented with SGLT2i associated DKA and one with euglycemic DKA. None of the patients presented with decompensated congestive HF. Three patients presented with concomitant acute medical conditions; Fournier’s gangrene, asthma exacerbation and alcoholic hepatitis. One patient developed acute stress induced cardiomyopathy while hospitalized. Another patient suffered cardiac arrest secondary to acidosis. Average duration of insulin infusion was 60 hours before resolution of DKA. All of the patients recovered. Conclusions In this single center study, we presented four unique cases of SGLT2i associated DKA in patients with T2DM and chronic HF. Diagnosis can be challenging as concomitant acute medical conditions and/or euglycemia can mask underlying DKA. Early diagnosis and management of SGLT2i associated DKA is important as this condition is life-threatening.

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

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

Abstract #1183828: The Role of Tacrolimus in DKA for Post-transplant Patients

Post-transplant diabetes (PTDM) is a well-known complication of immunosuppressants post organ transplantation. Calcineurin inhibitors (CNI), steroids, and mycophenolate (MMF) are standard therapy, with tacrolimus (TAC) being the most common CNI. It is well recognized that TAC decreases insulin secretion and causes beta cell apoptosis causing an insulin deficient state. However, diabetic ketoacidosis (DKA) has not yet been widely reported in transplant patients. We describe 3 cases of DKA in post-transplant patients on TAC. 1: 51yo male with hypertension, presented 2 months post kidney transplant with hyperglycemia for 1 week. Labs showed DKA with anion gap (AG) 28 mEq/L, CO2 6 mEq/L, pH 7.18, blood glucose (BG) >1500 mg/dL, beta hydroxybutyrate (BHB) 5.91 mmol/L. Immunosuppressants included prednisone, MMF, and TAC with a serum level of 13.1 ng/mL. Pretransplant A1C was 5.8% and increased to 10.3% at admission. Glutamic acid decarboxylate (GAD), islet cell, zinc transporter 8 Ab were negative, and C-peptide was 0.2ng/mL. He was treated with IV insulin and TAC dose adjusted. DKA resolved and he was discharged on insulin and a DPP4 inhibitor. 2: 57yo female with T2D, hypertension, congestive heart failure, presented 1-year post heart transplant with vomiting and abdominal pain for 1 day. Labs showed DKA with AG 22 mEq/L, CO2 19 mEq/L, pH 7.38, BG 267 mg/dL, BHB 3.16 mmol/L. Immunosuppressants included prednisone and TAC with level >30 ng/ml. A1C was 5.2%. She was treated with IV insulin. TAC was held and resumed after the level returned to range. DKA resolved and she was discharged on basal/bolus insulin and DPP4 inhibitor. 3: 68yo male with T2D, hypertension, ischemic cardiomyopathy presented 8 months post heart transplant with 1 month of hyperglycemia and weight loss. Labs showed DKA with AG 16 mEq/L, CO2 13 mEq/L, pH 7.38, BG 735 mg/dL, BHB 5.1 mmol/L Immunosuppressants included prednisone, MMF, and TAC with level of 7.0 ng/mL. Pretransplant A1C 7.1% and noted to be 12.2% at admission. Negative GAD, zinc transporter 8 Ab, and C-peptide 2.1ng/mL. He was treated with IV insulin. DKA resolved and he was discharged on basal/bolus insulin. We describe DKA in post-transplant patients within 12 months of transplant while on TAC without any other cause identified. All 3 had rapid improvement with insulin and adjustment of TAC doses. The negative effects of TAC on beta cells function causing an insulin deficient state could be an important precipitant of DKA in these patients. Close glucose monitoring is essential for early recognition and prevention. The risk factors for TAC associated DKA needs further study.

Abstract #1182972: Euglycemic PEA

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). DKA is more commonly seen in patients with type 1 DM rather than type 2 DM. Though in recent years the incidence of DKA in patients with type 2 DM has increased, including euglycemic DKA (EDKA), with frequent use of sodium glucose transporter 2 (SGLT2) inhibitors. We present a case of severe EDKA leading to pulseless electrical activity (PEA) cardiac arrest.

Optimized simplified pediatric diabetes severity warning system for the early identification of diabetic ketoacidosis in children.

Diabetic ketoacidosis (DKA) is the leading cause of mortality in children with type 1 diabetes. Diagnosis of DKA is difficult in resource-limited areas owing to the unavailability of blood gas test, the gold standard for DKA diagnosis. The Simplified Pediatric Diabetes Severity Warning System (SPDSWS) has been developed to identify high-risk DKA patients with limited resources in China. Here we optimized and validated this system. This study included 835 children admitted between January 2011 and June 2020 with the principal diagnosis of type 1 diabetes. Data were collected based on demographic and clinical characteristics. DKA and its severity were defined according to the criteria of ISPAD. SPDSWS was optimized based on logistic regression analyses and then was validated in a validation cohort. The 20-point optimized SPDSWS included strong positive urine ketone, young age, dehydration, fatigue, anorexia, vomiting, abdominal pain, abnormal pulse, and high blood glucose. The optimized SPDSWS predicted DKA with an AUC value of 0.882 in the derivation cohort. When the cut-point score ≥7 was used, the sensitivity and specificity were 75.5% and 86.0%, respectively, in the derivation cohort and were 90.0% and 85.8%, respectively, in the validation cohort. The optimized SPDSWS also predicted the moderate/severe DKA with an AUC value of 0.911 in the derivation cohort and 0.937 in the validation cohort. A score > 11 was associated with an extremely high incidence of DKA. The optimized SPDSWS could assist health care practitioners in underdeveloped remote areas to identify the children at high risk of DKA as early as on admission.

Diabetic ketoacidosis after the treatment of anaphylaxis.

SummaryAnaphylaxis is a rapidly progressive potentially lethal condition, and epinephrine is the most crucial medication in its treatment. In this study, we present a case of diabetic ketoacidosis in a young woman that was precipitated by the administration of epinephrine to treat anaphylaxis. This patient had diabetes mellitus and poor glycemic control and developed ketoacidosis despite having evidence of ongoing endogenous insulin production and having been treated with exogenous long-acting insulin less than 24 h prior to the event. This is a rare, serious, adverse side effect of life-saving medication. This report demonstrates that the risk of diabetic ketoacidosis should be considered when administering epinephrine to patients with diabetes, even in the absence of complete insulin deficiency.Learning pointsEpinephrine directly suppresses insulin secretion, stimulates lipolysis, and causes ketone body generation.High-dose catecholamine administration can cause unexpected diabetic ketoacidosis in patients with risk factors.Early administration of insulin may not protect patients from developing ketoacidosis in the setting of high-dose catecholamine administration.

Knowledge and Confidence of Iraqi Pediatric Residents in Management of Diabetic Ketoacidosis in Children

Background: Diabetic ketoacidosis (DKA) is a leading cause of mortality in children with type1 diabetes mellitus. Pediatric residents in Iraqi hospitals are usually the front liners in managingpediatric emergencies. Therefore, it is important to make sure they are practicing at the highestpossible standards to ensure patients’ safety. Objectives: this study evaluates the knowledge ofIraqi pediatric residents regarding DKA recognition and management and sheds the light on theareas that need further improvement. Methods: An online survey was conducted. A survey link toan online questionnaire using Survey Monkey was sent to residents at different levels between firstand fourth year of training (R1-R4) in general pediatrics. Results: About 60.9% of respondentsspent more than 6 months in pediatric emergency training. The majority of residents had treatedmore than 10 children presented with DKA, with the highest percentage (81.8 %) found amongR4s residents. Only 27.8% of residents recognized the diagnostic criteria of DKA. Three quartersof the participants could correctly calculate IV fluid infusion rate for maintenance by accountingfor the deficits and subtracting the boluses before calculating the corrections over 48 hours. 68.3%of respondents would not routinely attach DKA patients to a cardiac monitor unless the patient’scondition is unstable. 69.6% of survey respondents feel confident in treating children with DKA.Most participants (91.3%) think that there is a need for more DKA training/education sessions.Conclusions: Most of the respondents have a reasonable level of knowledge on how to manageDKA in children in Iraqi children’s hospitals. Some gaps in knowledge were identified and needto be highlighted in near future. Educational sessions for the residents about DKA management inchildren are deemed necessary.

Clinical Characteristics Associated with the Development of Diabetic Ketoacidosis in Patients with Type 2 Diabetes.

Objective This study analyzed the clinical and laboratory parameters that might influence the clinical outcomes of patients with type 2 diabetes who develop diabetic ketoacidosis (DKA), which has not been well investigated. Methods We reviewed the clinical and laboratory data of 158 patients who were hospitalized due to DKA between January 2006 and June 2019 and compared the data of patients stratified by the type of diabetes. In addition, the patients with type 2 diabetes were subdivided according to age, and their clinical and laboratory findings were evaluated. Results Patients with type 2 diabetes had a longer symptom duration associated with DKA, higher body mass index (BMI), and higher C-peptide levels than those with type 1 diabetes (p＜0.05). Among patients with type 2 diabetes, elderly patients (≥65 years old) had a longer duration of diabetes, higher frequency of DKA onset under diabetes treatment, higher effective osmolarity, lower BMI, and lower urinary C-peptide levels than nonelderly patients (＜65 years old) (p＜0.05). A correlation analysis showed that age was significantly negatively correlated with the index of insulin secretory capacity. Conclusion Patients with DKA and type 2 diabetes had a higher BMI and insulin secretion capacity than those with type 1 diabetes. However, elderly patients with type 2 diabetes, unlike younger patients, were characterized by a lean body, impaired insulin secretion, and more frequent DKA development while undergoing treatment for diabetes.

Treatment outcomes of diabetic ketoacidosis among diabetes patients in Ethiopia. Hospital-based study.

There was limited data on treatment outcomes among patients with diabetic ketoacidosis (DKA) in Ethiopia. The aim of the study was to determine the treatment outcomes of DKA patients attending Debre Tabor General Hospital. A retrospective study was conducted at Debre Tabor General Hospital and data were collected from June 1 to June 30 of 2018. Participants included in the study were all diabetic patients with DKA admitted from August 2010 to May 31, 2018. The primary outcomes were the treatment outcomes of DKA including (in-hospital glycemic control, the length of hospital stay and in-hospital mortality). The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics was presented in the form of means with standard deviation and binary regression was conducted to determine factors that affect length of hospital stay among DKA patients. 387 patients were included in the study. The mean age of patients was 33.30± 14.96 years. The most common precipitating factor of DKA was new onset diabetes mellitus 150(38.8%). The mean length of hospital stay was 4.64(±2.802) days. The mean plasma glucose at admission and discharge was 443.63(±103.33) and 172.94 (±80.60) mg/dL, respectively. The majority 370 (95.60%) of patients improved and discharged whereas 17 (4.40%) patients died in the hospital. Patients with mild and moderate DKA showed short hospital stay; AOR: 0.16 [0.03-0.78] and AOR:0.17[0.03-0.96] compared with severe DKA. Diabetic ketoacidosis precipitated by infection were nearly five times more likely to have long hospital stay than DKA precipitated by other causes; AOR: 4.59 [1.08-19.42]. In addition, serum glucose fluctuation during hospitalization increased the likelihood of long hospital stay, AOR: 2.15[1.76-2.63]. New onset type 1 diabetes was the major precipitating factor for DKA. Admitted DKA patients remained in hospital for a duration of approximately five days. About five out of hundred DKA patients ended up with death in the hospital. Infection, serum glucose fluctuations and severity of DKA were determinants of long hospital stay. Early prevention of precipitating factors and adequate management of DAK are warranted to reduce length of hospital stay and mortality.