Ketoacidosis In Patients Research Articles

THU387 Euglycemic Diabetic Ketoacidosis And SGLT-2 Inhibitor Use

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

To study risk factors and biochemical profile of diabetic ketoacidosis patients with special emphasis on serum amylase

Background: Diabetes mellitus (DM) is a complex endocrinological disorder with altered metabolism of blood glucose. Diabetic ketoacidosis (DKA) is one of the life-threatening acute complications of DM that mainly occurs in type 1 diabetes patients, as well as in some patients with type 2 diabetes. The mortality rate associated with DKA depends on the experience of the treating hospital in dealing with this condition; thus, it is critical that patients detect DKA and get medical help as soon as possible. Aims and Objectives: To study risk factors for DKA, clinical and biochemical profile of DKA patients. Correlation between serum amylase level, serum bicarbonate level and mean duration of hospital stay. Materials and Methods: A cross-sectional analytical study was carried out on 100 DKA patients in the Department of Medicine, SGMH Rewa, Madhya Pradesh from January 2021 to June 2022. The data extracted included clinical presentation, precipitating factors, laboratory profile, complications, and hospitalization outcomes. Results: Of the 100 patients admitted for DKA; 70 had type 2 diabetes (70%) and 30 (30%) were type I diabetes. The average age at the time of presentation was 48.61±19.59 years. The commonest precipitating factor was infection (38%) followed by other factors (62%). The most common clinical features at the time of presentation were altered sensorium, fever, vomiting, polyuria, polydipsia, weakness, lethargy, myalgia, headache, anorexia, abdominal pain, and orthopnea. The values for RBS, HCO3, and pH were 525.0±62.4, 12.6±2.69, and 7.14±0.31, respectively. There was no significant difference in clinical and biochemical profile of patients with type 1 and type 2 diabetes. The mortality rate was 3% and factors found to be significant predictors were comorbid condition, severity of mental status, severity of dehydration, RBS at the time of presentation, and severe acidosis. Conclusion: The most common precipitating factors are infection and omission of insulin or irregular treatment. The most common clinical features at the time of presentation are nausea, vomiting, abdominal pain, headache, and dehydration. There is no significant difference in the clinical and biochemical profile of patients with type 1 and type 2 diabetes. The mortality rate in DKA is 3% and the most notable predictors of poor prognosis are; severity of altered sensorium, severity of comorbid condition, severe dehydration, severe acidosis, and identification and treatment of precipitating factors are more important. Patient education plays a crucial role in the prevention of DKA.

Detecting Diabetic Ketoacidosis with Infection: Combating a Life-Threatening Emergency with Practical Diagnostic Tools.

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and can lead to patient demise if not immediately treated. From the recent literature, the diabetic ketoacidosis mortality rate, depending on age, is 2-5%. Insulin discontinuation and infection remain the two most common triggers for diabetic ketoacidosis. About 50% of cases of ketoacidosis result from bacterial infections like urinary tract infections and pneumonia. It is also important to diagnose the presence of infection in diabetic ketoacidosis patients to prevent the excessive use of antibiotics, which may lead to antibiotic resistance. Although performing bacterial culture is confirmatory for the presence or absence of bacterial infection, the time required to obtain the result is long. At the same time, emergency treatment needs to be started as early as possible. This narrative review examines various septic markers to identify the appropriate tools for diagnosis and to distinguish between diabetic ketoacidosis with and without infection. Electronic databases were searched using the Google engine with the keywords "Diabetes Mellitus", "Diabetic Ketoacidosis", "Infection with Diabetic Ketoacidosis", "biomarkers for infection in Diabetic Ketoacidosis", "Procalcitonin", "Inflammatory cytokines in DKA", "Lactic acidosis in DKA", and "White blood cell in infection in DKA". This narrative review article presents the options for diagnosis and also aims to create awareness regarding the gravity of diabetic ketoacidosis with infection and emphasizes the importance of early diagnosis for appropriate management. Diabetes mellitus is a clinical condition that may lead to several acute and chronic complications. Acute diabetic ketoacidosis is a life-threatening condition in which an excess production of ketone bodies results in acidosis and hypovolemia. Infection is one of the most common triggers of diabetic ketoacidosis. When bacterial infection is present along with diabetic ketoacidosis, the mortality rate is even higher than for patients with diabetic ketoacidosis without infection. The symptoms and biomarkers of diabetic ketoacidosis are similar to that of infection, like fever, C reactive protein, and white blood cell count, since both create an environment of systemic inflammation. It is also essential to distinguish between the presence and absence of bacterial infection to ensure the appropriate use of antibiotics and prevent antimicrobial resistance. A bacterial culture report is confirmatory for the existence of bacterial infection, but this may take up to 24 h. Diagnosis needs to be performed approximately in the emergency room upon admission since there is a need for immediate management. Therefore, researching the possible diagnostic tools for the presence of infection in diabetic ketoacidosis patients is of great importance. Several of such biomarkers have been discussed in this research work.

Differences of BUN and Serum Creatinine Values in Severity of Diabetic Ketoacidosis Patients at RSD dr. Seobandi Jember

Differences of BUN and Serum Creatinine Values in Severity of Diabetic Ketoacidosis Patients at RSD dr. Seobandi Jember

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Overlapping risk factors for diabetic ketoacidosis in patients with type 1 diabetes on ipragliflozin: case analysis of spontaneous reports in Japan from a pharmacovigilance safety database

ABSTRACT Background In patients with type 1 diabetes mellitus (T1D), sodium-glucose cotransporter 2 (SGLT2) inhibitors are associated with an increased risk of diabetic ketoacidosis (DKA). Ipragliflozin is an SGLT2 inhibitor approved in Japan in combination with insulin for patients with T1D. Research design and methods Spontaneous safety reports of ipragliflozin adverse drug reactions (ADRs) in patients with T1D were collected during early post-marketing phase vigilance (EPPV; 21 December 2018–20 June 2019). For patients with T1D prescribed ipragliflozin who experienced DKA, we examined DKA event data registered in the manufacturer’s safety database (21 December 2018–31 December 2021), including patient background characteristics. Results During EPPV, there were 189 total events (45 serious) of ADRs, including 32 serious events of ketoacidosis. From 2018 to 2021, the major DKA risk factors were sick days, stopping or inappropriately decreasing insulin, insulin pump trouble, and low carbohydrate diet, with substantial overlap among these factors. Conclusions In Japanese patients with T1D using ipragliflozin, DKA events were linked to several overlapping factors, including sick days and reduced dose/interruption of insulin, whether intentional or unexpected. These results highlight the need for improved patient education regarding ipragliflozin use and appropriate self-management of ketosis from an early stage.

Continuous glucose monitoring versus blood glucose monitoring for risk of severe hypoglycaemia and diabetic ketoacidosis in children, adolescents, and young adults with type 1 diabetes: a population-based study

The effect of continuous glucose monitoring on the risk of severe hypoglycaemia and ketoacidosis in patients with diabetes is unclear. We investigated whether rates of acute diabetes complications are lower with continuous glucose monitoring, compared with blood glucose monitoring, and which metrics predict its risk in young patients with type 1 diabetes. In this population-based cohort study, patients were identified from 511 diabetes centres across Austria, Germany, Luxembourg, and Switzerland participating in the Diabetes Prospective Follow-up initiative. We included people with type 1 diabetes aged 1·5-25·0 years, with a diabetes duration of more than 1 year, who had been treated between Jan 1, 2014, and June 30, 2021, and had an observation time of longer than 120 days in the most recent treatment year. Severe hypoglycaemia and ketoacidosis rates during the most recent treatment year were examined in people using continuous glucose monitoring and in those using blood glucose monitoring. Adjustments of statistical models included age, sex, diabetes duration, migration background, insulin therapy (pump or injections), and treatment period. Rates of severe hypoglycaemia and diabetic ketoacidosis were evaluated by several continuous glucose monitoring metrics, including percentage of time below target glucose range (<3·9 mmol/L), glycaemic variability (measured as the coefficient of variation), and mean sensor glucose. Of 32 117 people with type 1 diabetes (median age 16·8 years [IQR 13·3-18·1], 17 056 [53·1%] males), 10 883 used continuous glucose monitoring (median 289 days per year), and 21 234 used blood glucose monitoring. People using continuous glucose monitoring had lower rates of severe hypoglycaemia than those using blood glucose monitoring (6·74 [95% CI 5·90-7·69] per 100 patient-years vs 8·84 [8·09-9·66] per 100 patient-years; incidence rate ratio 0·76 [95% CI 0·64-0·91]; p=0·0017) and diabetic ketoacidosis (3·72 [3·32-4·18] per 100 patient-years vs 7·29 [6·83-7·78] per 100 patient-years; 0·51 [0·44-0·59]; p<0·0001). Severe hypoglycaemia rates increased with percentage of time below target glucose range (incidence rate ratio 1·69 [95% CI 1·18-2·43]; p=0·0024, for 4·0-7·9% vs <4·0% and 2·38 [1·51-3·76]; p<0·0001, for ≥8·0% vs <4·0%) and glycaemic variability (coefficient of variation ≥36% vs <36%; incidence rate ratio 1·52 [95% CI 1·06-2·17]; p=0·022). Diabetic ketoacidosis rates increased with mean sensor glucose (incidence rate ratio 1·77 [95% CI 0·89-3·51], p=0·13, for 8·3-9·9 mmol/L vs <8·3 mmol/L; 3·56 [1·83-6·93], p<0·0001, for 10·0-11·6 mmol/L vs <8·3 mmol/L; and 8·66 [4·48-16·75], p<0·0001, for ≥11·7 mmol/L vs <8·3 mmol/L). These findings provide evidence that continuous glucose monitoring can reduce severe hypoglycaemia and ketoacidosis risk in young people with type 1 diabetes on insulin therapy. Continuous glucose monitoring metrics might help to identify those at risk for acute diabetes complications. German Center for Diabetes Research, German Federal Ministry of Education and Research, German Diabetes Association, and Robert Koch Institute.

A retrospective study on comparison of clinical characteristics and outcomes of diabetic ketoacidosis patients with and without acute pancreatitis

The co-existence of diabetic ketoacidosis (DKA) with acute pancreatitis (AP) is associated with unfavorable clinical outcomes. However, diagnosing AP in DKA patients is challenging and often missed due to overlapping symptoms. The aim of this retrospective observational study was to compare the clinical characteristics and outcomes of patients with concomitant DKA and AP or DKA alone. Data of patients with DKA admitted between January 2015 to August 2021 to four hospitals in Qatar was extracted from the electronic health record (Cerner). American Diabetes Association criteria and Atlanta criteria were used for DKA and AP diagnosis, respectively. Independent T-test or Mann–Whitney U test was used to analyze continuous variables, whereas categorical variables were analyzed via Chi-square or Fischer exact tests as appropriate. Univariate and multivariate logistic regression models were generated to assess the correlations. A p-value of < 0.05 was considered statistically significant. Of 936 patients with DKA, 84 (9.0%) had coexisting AP. AP was most common in the Asian race (66%, p < 0.001). Patients with DKA and AP were older, had higher admission anion-gap, white cell count, hemoglobin (hb), neutrophil/lymphocyte ratio, urea, creatinine, maximum blood glucose during the episode, total cholesterol and triglyceride level (TGL) (p < 0.05). They had a lower admission venous pH and bicarbonate at 6 h. Patients in the DKA with AP group also had a longer length of stay (LOS), DKA duration and a higher rate of ICU admission (p-values ≤ 0.001). In-hospital mortality, 3-month all-cause readmission, 6-month and 12-month DKA recurrence did not differ between the two groups. Univariate logistic regression analysis showed age, Asian ethnicity, male gender, T2D, admission WBC count, hb, urea, creatinine, potassium, venous pH, bicarbonate, anion gap, total cholesterol, TGL and LDL level were significantly associated with the development of DKA with AP (p < 0.05). In multivariate logistic regression analysis, age and total cholesterol level were associated with concomitant DKA and AP (p < 0.05). Patients with concomitant DKA and AP have more severe derangement in markers of DKA severity, inflammation, kidney injury and metabolic profile, along with a longer DKA duration, LOS and requirement for ICU support compared to DKA patients without AP. This highlights the clinical significance of diagnosing the co-existence of DKA with AP, as the combination results in significantly worse clinical outcomes and greater healthcare utilization than in patients with only DKA.

Elevated alanine transaminase is nonlinearly associated with in-hospital death in ICU-admitted diabetic ketoacidosis patients

AimsTo investigate the association between alanine transaminase (ALT) and in-hospital death in patients admitted to the intensive care unit for diabetic ketoacidosis (DKA). MethodsA cohort of 2,684 patients was constructed from the eICU Collaborative Research Database. Baseline demographic and clinical characteristics were summarized. Cox regressions with restricted cubic spline functions were modelled to explore the association between alanine transaminase and in-hospital death. Subgroup analyses were conducted between sexes, age groups, and people with/without obesity. ResultsAfter adjusting multiple confounders, a nonlinear, S-shaped association between ALT and in-hospital death was found. Compared to patients at median ALT, patients at the 90th percentile of ALT have a 1.88 (95 % confidence interval [CI]: 1.34–2.62) times higher hazard of in-hospital death in the unstratified cohort. Similar results were found in males (hazard ratio [HR] = 1.69, 95 % CI: 1.24–2.30); patients aged under 65 years (HR = 1.65, 95 % CI: 1.09–2.49); patients aged 65 years or above (HR = 3.45, 95 % CI: 1.67–7.14); non-obese patients (HR = 1.52, 95 % CI: 1.00–2.32); and obese patients (HR = 2.76, 95 % CI: 1.38–5.54). ConclusionsElevated ALT is robustly associated with in-hospital death in ICU-admitted DKA patients across several subgroups. Close monitoring of ALT in these patients is recommended.

Electrolytes and Enzymes Variations in Diabetic Keto Acidosis

Objective: This study aims to evaluate the levels of serum electrolytes and enzymes in diabetic ketoacidosis compared with age matched healthy control population. Method: Cross sectional study involving 94 individuals above the age 60 years in the population of Bengaluru, India between October 2017 to November 2019.Venous blood was collected from 47 type 2 diabetic ketoacidosis patients and from 47 healthy individuals and analyzed for sodium, chloride, potassium, phosphorous electrolytes and serum amylase and lipase enzymes. Results: Serum sodium, potassium and chloride levels were significantly low while serum phosphorous, amylase and lipase levels were significantly high compared to healthy control population. Conclusion: Frequent monitoring of these electrolytes and enzymes in mild stage of diabetic ketoacidosis may help in better treatment and thereby preventing it from progressing into severe diabetic ketoacidosis.

Clinical Characteristics and Outcomes of Diabetic Ketoacidosis in Patients With Type 2 Diabetes using SGLT2 Inhibitors.

Sodium glucose cotransporter 2 inhibitors (SGLT2i) use is associated with an increased risk of diabetic ketoacidosis (DKA). This study evaluated and compared the DKA characteristics and outcomes of users and non-users of SGLT2i. We retrospectively studied patients with type 2 diabetes mellitus (T2DM) admitted with DKA to Tawam Hospital, Al Ain City, UAE between January 2017 and March 2021. Demographic data, clinical, and laboratory findings were extracted from the electronic medical records. A total of 55 patients with T2DM (62% UAE nationals, 50% women) were admitted with DKA. The average age was 54.0 ± 18.9 years and average diabetes duration of 15.7 ± 15.1 years. Seventeen patients (31%) were using SGLT2i. Infection was the main precipitating factor for DKA in (8 out of 17) SGLT2i users. Compared to non-users, SGLT2i users had lower systolic blood pressure (119.9 vs 140 mmHg; P = .012) and serum glucose levels (16.2 vs 24.9 mmol/L; P < .001) and higher Na level (137.5 vs 132.6 mmol/L; P = .005). Additionally, 56.3% of SGLT2i users had euglycemic DKA compared to 2.6% of nonusers (P < .001). Acute kidney injury (AKI) occurred more in SGLT2i users compared to non-users (94.1% vs 67.6%, P = .043). Further analysis revealed that SGLT2i users were about five times more likely to have prolonged hospital length of stay (⩾14 days) when compared with non-users (adjusted OR: 4.84; P = .035). Overall, there was no difference between the two groups with regards to DKA complications and mortality. SGLT2i related DKA is associated with lower blood glucose levels, lower SBP, worse hypovolemia, increased risk of AKI, and longer hospital stay when compared to non SGLT2i related episodes. Since the benefits of SGLT2 inhibitors far outweigh potential risks, there is a need to raise healthcare professionals and patients' awareness about this potential association.

Predictive Value of Sepsis Markers in Diabetic Ketoacidosis Patients Admitted to Intensive Care Unit

Predictive Value of Sepsis Markers in Diabetic Ketoacidosis Patients Admitted to Intensive Care Unit

The Association between SARS-CoV-2 Infection and Diabetic Ketoacidosis in Patients with New-Onset Diabetes: A Retrospective Study from a Diabetic Center in Saudi Arabia.

Various reports described new-onset diabetes during or after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with no previous history of diabetes or glucocorticoid use. Further, SARS-CoV-2 could increase the risk of diabetes, including diabetic ketoacidosis (DKA). However, data on the relationship between new-onset diabetes and COVID-19 are still limited in our region. Thus, we aimed in this study to evaluate the association between new-onset diabetes and DKA in patients with COVID-19. A retrospective, cross-sectional study was conducted at a diabetic center in Jazan province, Saudi Arabia, between 2020 and 2021. Demographic data, COVID-19 status, and DKA incidence were collected and verified manually from diabetic patients' medical records. Data were analyzed using a t-test and chi-square test. We included 54 diabetic patients diagnosed during the COVID-19 pandemic, with a median age of 17 years. The majority of patients were females (57.4%). About 38.8% were diagnosed with COVID-19, and 16.6% reported having DKA. About 33.3% of the patients who experienced DKA reported being COVID-19-positive. However, only 6% of patients who denied contracting SARS-CoV-2 developed DKA (p-value = 0.020). Patients with newly diagnosed diabetes due to COVID-19 seem at a higher risk of developing DKA. Further epidemiological and molecular studies are required for a better understanding of the correlation between DKA in patients with diabetes and COVID-19.

An Audit of Factors Impacting the Time to Resolution of the Metabolic Parameters in Diabetic Ketoacidosis Patients.

Diabetic ketoacidosis (DKA) is a major complication affecting patients with diabetes. It is often the first presentation of type I diabetes and can also occur due to a lack of compliance with insulin therapy or infection, among other causes. Hospitalizations for DKA have increased globally among patients with type I and type II diabetes, which poses a strain on health systems. To determine the factors impacting the time to resolution of metabolic parameters in DKA patients. This retrospective study was performed by reviewing the clinical records of hospitalized DKA patients at King Fahad Specialist Hospital, a tertiary-level healthcare center in Buraidah, Al Qassim region, Saudi Arabia. The study included all DKA admissions that met the inclusion criteria between September 2019 and April 2022. A total of 129 patients with a diagnosis of DKA from January 2019 to April 2022 were identified. Of these, 67 patients met the inclusion criteria. More females experienced DKA (56.7%), and the study population had an improvement rate of 97%. The mean length of stay (LOS) for patients with DKA was 73.19 hours, and the median time for DKA resolution was 15 hours (mean time 21.38 hours). The omission of insulin was the leading precipitating factor for DKA (43%) followed by infection (12%). A high serum bicarbonate (HCO3) level was identified as an independent predictor for a longer time to resolution. Patients with DKA who have high glucose levels on admission, higher body mass index (BMI), older age, and higher weight stayed in the hospital for extended periods. Conversely, patients with a higher serum potential of Hydrogen (pH) had a shorter LOS. Age was the only clinically independent predictor for a minimum LOS for DKA. Patients with comorbidities had a longer hospital LOS than patients without comorbidities; no such relationship has been reported in other studies. Patients in our study population had a longer time of resolution than observed in other studies, although no clear cause was identified. This study contributes to our understanding of DKA in hospitalized patients in Saudi Arabia. This is the first study to link patients with DKA who have comorbidities to a longer hospitalstay in the kingdom of Saudi Arabia. This study also identified multiple clinical and biochemical parameters related to the variability in LOS and time to resolution of DKA in hospitalized patients.

ODP183 Diabetic Ketoacidosis Precipitated by Ketogenic Diet and SGLT-2 Inhibitor Use in an Individual with T2DM

Abstract Background SGLT-2 inhibitors have been associated with increased risk of ketoacidosis even with normal blood glucose levels. A ketogenic diet is a low-carb, high-fat diet which has recently gained popularity for weight loss by producing a state of ketosis. We present this case to emphasize the risk of ketoacidosis in patients on SGLT-2 inhibitors and a ketogenic diet. Clinical Case A 48-year-old woman with a 16-year history of T2DM presented to the ER with a 3-day history of upper abdominal cramping and headaches, decreased urine output, and progressively worsening nausea and vomiting. Her glycated hemoglobin level was 9.4% (n: 4-6%) and her blood glucose readings were not elevated during this time. Other medical issues include dyslipidemia, transaminitis and hypertension. She does not smoke or drink alcohol. She takes glimepiride 0.5 mg daily and canagliflozin was added approximately 1.5 weeks prior to presentation. She was on a ketogenic diet. A few days prior to these symptoms she was in the process of moving out of her home, spending long days physically exerting herself. On exam she was in mild distress with dry mucous membranes. Vitals showed tachycardia (119BPM) but otherwise were stable. Labs revealed that she was severely acidotic with an anion gap of &amp;gt;27 and pH &amp;lt; 6.9 (n: 7.34-7.43), with urinalysis positive for ketones (2+, n: negative), protein (3+, n: negative), and glucose (3+, n: negative). Complete blood count showed leukocytosis (WBC: 18,000, n: 4. 00-12. 00*10 3 /mcL). Complete metabolic panel showed hyponatremia (130, n: 136-145mmol/L), elevated glucose (305, n: 70-99,g/dL), and low bicarbonate (&amp;lt;5, n: 22-30mmol/L). A chest X-ray, lumbar puncture and CT of head and abdomen were unrevealing. She was admitted to the ICU for treatment of suspected DKA with severe acidosis and hypovolemia. She was hydrated with IV fluids and was started on an insulin drip according to DKA protocol. Her anion gap closed in 22 hours. The patient spent 3 days in the ICU and 1 day on general floor before discharge on home medications and was advised to follow up with endocrinology. At follow up 2 months later her C-peptide was 2.14 (0.78-5.19 ng/mL) and GAD65 antibody assay was 0. 00 (&amp;lt;0. 02 nmol/L), the SGLT-2 inhibitor was discontinued, and she was instead started on a GLP-1 agonist. Conclusion The mechanism behind DKA with SGLT-2 inhibitor use involves glycosuria and volume depletion, lowering the insulin-to-glucagon ratio, while stimulating lipolysis. The addition of a low carbohydrate or ketogenic diet produces a state of ketosis as fat is utilized for energy and ketones are produced, further promoting DKA. With increased use of SGLT-2 inhibitors in patients with and without diabetes mellitus extreme caution should be exercised in prescribing SGLT-2 inhibiters in a patient on a low carbohydrate diet. Presentation: No date and time listed

PSUN139 Leukemoid Reaction in Severe Diabetic Ketoacidosis: An Indicator of Severity or Predictor of Infection?

Abstract Background Acute infectious illness can precipitate episodes of ketoacidosis in patients with diabetes mellitus. For this reason, a diligent search for a focus is essential in the initial evaluation of patients with DKA since patients often appear ill and may have non-specific symptoms. Clinical Case An 18-year old Filipino with Type 1 Diabetes Mellitus sought consult due to abdominal pain. He is on premixed NPH/regular insulin twice daily but was lost to follow-up due to the COVID-19 pandemic. He has no other comorbidities but asserted a prior history of poor compliance with both diet and insulin therapy besides an erratic sleep-wake cycle. Prior to consult, he reported 5 episodes of vomiting associated with generalized abdominal pain. Due to poor appetite, he missed due doses of insulin with subsequent worsening of condition. On admission, he was lethargic with Kussmaul's breathing. Initial vital signs were stable. He had dry lips and oral mucosa, sunken eyeballs and generalized abdominal tenderness. COVID-19 PCR was negative. Serum lipase (8.79, n: 8-78) and CT scan of abdomen were likewise unremarkable. Initial CBG was HIGH with elevated ketones (5.4, n: &amp;lt;0.6) and arterial blood gas revealed a pH of 7.0, pCO2 22, HCO3 incalculable, lactate 3.9, with high anion gap. The initial WBC was high (44.3×109/uL, n: 4.4-11) with 84% neutrophils, 10% lymphocytes, 1% metamyelocytes, and 5% monocytes. Hemoglobin (18.5 g/dl), hematocrit (51.7%) and platelet count (614k/uL) were also elevated. Peripheral blood smear revealed normal cell morphology. Urinalysis revealed elevated specific gravity, marked glycosuria and ketonuria, negative nitrites and leukocyte esterases. Blood specimen were obtained for culture. Therapy was instituted with intravenous fluids, insulin drip and broad spectrum antibiotics. The following day, glucose was 218 mg/dl, pH 7.16, bicarbonate 7.8 meq/L, hematocrit 44%, WBC 25.21×109/uL and platelet count was 401k/uL. LAP score was requested but was unavailable. On the fourth hospital day, the patient was well and tolerating diet, with normalization of blood glucose, WBC 9.87 (85% neutrophils, 10% lymphocytes, 5% monocytes) and control of acidosis. Since cultures were negative and patient was afebrile, antibiotics were discontinued. He was discharged stable on with basal-bolus insulin. Conclusion The association between DKA and leukocytosis in the absence of infection is described in literature. Exact mechanism is unknown but may in part be attributed to increased catecholamine release in response to stress and hemoconcentration from marked dehydration. Studies show a statistically significant relationship between pH, bicarbonate and leukocytes which denotes that WBC in DKA can be an indicator of the severity of ketoacidosis rather than a predictor of infection. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

A Population-Based Study of SGLT2 Inhibitor-Associated Postoperative Diabetic Ketoacidosis in Patients with Type 2 Diabetes.

Operations are a major precipitating factor for sodium-glucose co-transporter 2 inhibitor (SGLT2i)-associated diabetic ketoacidosis (DKA). This study aimed to investigate the risks of SGLT2i-associated postoperative DKA. We analysed a population-based cohort of patients with type 2 diabetes who underwent operations during 2015-2020. Patients with SGLT2i prescriptions within 6months before operations were assigned to the SGLT2i group, while others were assigned to the control group. Inverse probability treatment weighting with propensity scores was used to balance the baseline covariates. Postoperative DKA was defined as DKA within 30 days postoperatively. Overall, 147,115 subjects were included (3,419 SGLT2i users; 143,696 controls). Preoperative SGLT2i exposure was associated with increased risks of postoperative DKA (incidence=6.40/1,000 person-years; incidence rate ratio [IRR]6.33, 95% confidence interval [CI] 5.57-7.18; p<0.001). Risk factors of SGLT2i-associated postoperative DKA included emergency operation (IRR 24.56, 95% CI 7.42-81.24; p<0.001), preoperative HbA1c ≥8% (IRR 3.10, 95% CI 1.31-7.33; p=0.010) and insulin use (IRR 2.88, 95% CI 1.27-6.51; p=0.011). SGLT2i users who developed postoperative DKA had worse outcomes (invasive mechanical ventilation, dialysis, infections/sepsis, intensive care, and length of hospitalization; p<0.05) than those who did not, although SGLT2i users who developed postoperative DKA had better outcomes than non-SGLT2i users who developed postoperative DKA (p<0.05). The risk of postoperative DKA decreased following the implementation of an automatic electronic health record pop-up alert on perioperative precaution regarding SGLT2i (from IRR 4.06 [95% CI 3.41-4.83] to 2.97 [95% CI 2.41-3.65]; p for interaction=0.020). Preoperative SGLT2i use was associated with increased risks of postoperative DKA in patients with type 2 diabetes. Clinicians could optimize patients' outcomes by appropriate prescription of SGLT2i, while watching out for high-risk features. Implementing automatic electronic health record pop-up alerts may reduce the risk of SGLT2i-associated postoperative DKA.

Outcomes in hospitalised diabetic ketoacidosis patients with underlying heart failure: a national inpatient sample analysis

Abstract Management of diabetic ketoacidosis (DKA) is challenging in patients with heart failure as they tend to be fluid sensitive. We conducted this study to assess the impact of heart failure (HF) on in-hospital outcomes in patients hospitalized with DKA. We conducted this cohort study using the national inpatient sample database from 2017 and 2018. The International Classification of Diseases-10 codes were used to identify patients with DKA as the principal diagnosis and stratified them based on whether they had HF. The outcomes were in-patient mortality, length of stay, total hospital charges, and complications during the hospitalization. We used multivariate regression analysis to adjust for confounders. Among the 446,339 total hospitalized for DKA, 20,210 had a secondary diagnosis of HF. The average age was 57 (HF) vs 38 (no HF) (p&amp;lt;0.001). In the HF group, 56% were male and 56% were caucasian. After adjusting for patient demographics, comorbidities, and hospital characteristics, patients with HF had higher odds of cardiogenic shock (aOR=3.77, p&amp;lt;0.001, CI: 1.89–7.49), pneumonia (aOR=1.37, p&amp;lt;0.001, CI: 1.18–1.60), Total hospital charges (coefficient= $5,894.20, p&amp;lt;0.001, CI: 3046–8741) and length of stay (coefficient 0.35 days, p=0.001, CI: 0.14–0.56). There was no statistically significant difference in mortality, cardiac arrest, and sepsis. Patients with HF had lower odds of developing acute kidney injury (aOR=0.66, p&amp;lt;0.001, 0.62–0.72). Among hospitalized patients with DKA, those with HF had worse outcomes in terms of length of stay, total hospital charges, cardiogenic shock, and pneumonia. However, there was no statistically significant increase in inpatient mortality. Funding Acknowledgement Type of funding sources: None.

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.

Potential Clinical Applications for Continuous Ketone Monitoring in the Hospitalized Patient with Diabetes.

Purpose of ReviewIn this review, the authors discuss potential clinical applications for continuous ketone monitoring (CKM) in a broad continuum of clinical settings from pre-hospital care and the emergency department to acute inpatient management and post-discharge follow-up.Recent FindingsThough in its early stages, the concept of a novel continuous ketone sensing technology exerts great potential for use in the detection and hospital management of DKA, namely to overcome diagnostic barriers associated with ketoacidosis in patients with diabetes and obtain real-time BOHB levels, which may be useful in understanding both patients’ response to treatment and DKA trajectory. Peri- and intra-operative use of CKM technology can potentially be applied in a number of urgent and elective surgical procedures frequently underwent by patients with diabetes and in the observation of patients during peri-operative fasting. In transitional care management, CKM technology could potentially facilitate patients’ safe transition through levels of care, following hospital discharge from a DKA episode.SummaryThis evaluation of the literature presents the potential advantages of adopting CKM and integrating this technology into the care algorithm of patients at risk for ketoacidosis.