Clinical Profile of Diabetic Ketoacidosis: A Prospective Study in a Tertiary Care Hospital

Effectiveness of interventions for emergency care of hypoglycaemia and diabetic ketoacidosis: A systematic review

AIM

This systematic review aims to provide evidence on effectiveness of interventions used in emergency care of hypoglycaemia and diabetic ketoacidosis (DKA).

METHODOLOGY

This is a systematic review of randomized controlled trials and analytical studies. We selected studies based on eligibility criteria. The databases Medline, Cochrane library and Embase were searched from their inception till November 2, 2022, using search strategy. We used the term such as "diabetes mellitus", "treatment", "hypoglycaemia", "diabetic ketoacidosis", "low blood sugar", "high blood sugar" and Mesh terms like "disease management", "hypoglycaemia", "diabetic ketoacidosis", and "diabetes mellitus" to form search strategy.

RESULTS

Hypoglycemia: Both 10 % dextrose (D10) and 50 % dextrose (D50) are effective options with similar hospital mortality D10 (4.7 %) and D50 (6.2 %). DKA: Low dose insulin is non-inferior to standard dose with time till resolution of DKA 16.5 (7.2) hours and 17.2 (7.7) hours (p value = 0.73) respectively. In children, subcutaneous insulin was associated with reduced ICU admissions and hospital readmissions (67.8 % to 27.9 %). Plasmalyte (PL) is noninferior to sodium chloride (SC), with ICU length of stay 49 h (IQR 23-72) and 55 h (IQR 41-80) respectively, hyperchloremia was associated with longer in-hospital length of stay and longer time to resolution of DKA. And potassium replacement at < 10 mmol/L was associated with higher mortality (n = 72).

CONCLUSION

We conclude either of the 10 % or 50 % dextrose is effective for management of hypoglycaemia. For DKA subcutaneous insulin and intravenous insulin, chloride levels ≤ 109 mEq/L, potassium above 10 mmol/l, IV fluids like Plasmalyte and normal saline are effective.

Outcome of Diabetic Keto Acidosis Treatment and Associated Factors Among Adult Patients Admitted to Emergency and Medical Wards at St. Paul's Hospital, Addis Ababa Ethiopia, 2023: A Cross-Sectional Study

Background

Diabetic ketoacidosis is a potentially fatal disease that affects adults. Therefore, rapid detection and treatment are required to decrease mortality rates. Most of the earlier research on diabetic ketoacidosis in Ethiopia concentrated on its prevalence and associated factors. This study aimed to assess the treatment outcomes of diabetic ketoacidosis and its associated factors in adult patients admitted to St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, in 2023.

Methods

This institution-based retrospective cross-sectional study was conducted with a sample size of 357. The data were entered in Epidata version 4.6 and exported to the Statistical Package for the Social Sciences (SPSS) version 25 for analysis. Adjusted Odds Ratio (AOR) with a 95% confidence interval was estimated to determine its association with outcome of treatment.

Results

Three hundred fifty-seven diabetic ketoacidosis patients' charts were reviewed. Fourteen (3.9%) diabetic ketoacidosis (DKA) patients had died. Those Patients with diabetic ketoacidosis who had acute comorbidity (presence of sepsis) (AOR = 3.24, 95% CI: 1.20-10.2), international unit (IU) insulin administration in the 1st 24 hours (AOR = 8.046, 95% CI: 3.881-25.32), fluid replacement in the 1st 24 hours (AOR = 5.84, 95% CI: 1.53-10.07), and potassium replacement (AOR = 3.08, 95% CI: 1.835-5.817) were independently associated with treatment outcome of diabetic ketoacidosis. Insulin administration for the first 24 hours more than >60 IU insulin showed improvement in treatment outcome by 8.04 times more likely than less <60 IU insulin administration for the first 24 hours. More >6 liters fluid replacement in the first 24 hours had improvement in treatment outcome by 5.84 times more likely than <6 liters fluid replacement.

Conclusion

A considerable proportion of the patients with diabetic ketoacidosis died at St. Paul's hospital millennium medical college. Stakeholders must emphasize the treatment of patients with diabetes (diabetic ketoacidosis), according to the recommendations of local and international guidelines.

Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter 2 Inhibitors: Clinical and Biochemical Characteristics of 29 Cases

Objective

To describe the clinical and biochemical characteristics of all reported cases of DKA associated with SGLT2 inhibitor use in patients with type 2 diabetes mellitus and to identify potential risk factors.

Design

A retrospective case series was conducted between March 2013 and August 2019 using an electronic medical record search algorithm.

Results

25 patients met the criteria for DKA associated with SGLT2i use (total of 29 cases), 15 were female, average age was 54.24 years, and mean diabetes duration was 8.76 years. The majority of the patients (23 patients) had no history of prior DKA. Average blood glucose concentrations at presentation were 298.9 ± 152.7 mg/dl. Interestingly, nearly half of the episodes (14) met the criteria of euglycemic DKA (glucose <250 mg/dl). Average anion gap values were 26.59 ± 6.15 mg/dl, bicarbonate values were 11.14 ± 5.57 mg/dl, and pH values were 7.16 ± 0.12. All had positive serum and urine ketones. The most common presenting symptoms were nausea, vomiting (18 cases), and abdominal pain (10 cases). Common precipitants were poor oral intake (18 cases) and infection (10 cases). A variety of drugs were prescribed along with an SGLT2i, and 11 of the patients were using insulin. None of the cases were fatal. Comparison between euglycemic DKA and hyperglycemic DKA did not identify any significant difference. A major limitation factor of the study was the lack of control group or comparison to other antiglycemic agents to assess the relative risk.

Conclusions

The majority of SGLT2i-associated DKA cases occurred in patients with T2DM without prior episodes of DKA. The most common presenting symptoms were nausea, vomiting, and abdominal pain, while poor food intake and infection were the main precipitants. Clinicians should consider the possibility of DKA in SGLT2i-treated patients presenting with these symptoms, even in absence of marked hyperglycemia.

Diabetic Ketoacidosis among Diabetic Patients Admitted in the Department of Medicine of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Diabetic ketoacidosis is one of the most severe acute complications of diabetes mellitus characterised by hyperglycemia, hyperketonemia, and metabolic acidosis. Prompt diagnosis and treatment of diabetic ketoacidosis can decrease severity, hospital stay, and possible mortality. This study aimed to find out the prevalence of diabetic ketoacidosis among diabetic patients admitted to the department of medicine of a tertiary care centre.

Methods

This descriptive cross-sectional study was conducted at a tertiary care centre. Data from 1 March 2022 to 1 December 2022 were collected between 1 January 2023 and 1 February 2023 from the hospital records. The ethical approval was taken from the Institutional Review Committee of the same institute (Reference number: 466/2079/80). All the diabetic patients admitted to the Department of Medicine during our study duration were enrolled for the study. Diabetic patients who left against medical advice and those with incomplete data were excluded from the study. Data were collected from the medical record section. Convenience sampling method was done. Point estimate and 95% Confidence Interval were calculated.

Results

Among 200 diabetic patients, the prevalence of diabetic ketoacidosis was 7 (3.5%) (3.47-3.53, 95% Confidence Interval) among which 1 (14.29%) patients had type I diabetes mellitus and 6 (85.71%) had type II diabetes mellitus patients and the mean HbA1C level was 9.77%.

Conclusions

The prevalence of diabetic ketoacidosis among diabetes mellitus patients admitted to the department of medicine of a tertiary care centre was found to be higher than in other studies done in similar settings.

Keywords

diabetes mellitus; diabetic complications; diabetic ketoacidosis; Nepal.

The global impact of COVID-19 pandemic on the incidence of pediatric new-onset type 1 diabetes and ketoacidosis: A systematic review and meta-analysis

Viral infections may increase the risk of developing type 1 diabetes (T1D), and recent reports suggest that Coronavirus Disease 2019 (COVID-19) might have increased the incidence of pediatric T1D and/or diabetic ketoacidosis (DKA). Therefore, this meta-analysis aims to estimate the risk of global pediatric new-onset T1D, DKA, and severe DKA before and after the COVID-19 pandemic. A systematic search of MEDLINE/PubMed, CINAHL, Scopus, and EMBASE was conducted for articles published up to March 2022. A random-effects meta-analysis was performed to compare the relative risk of T1D and DKA among pediatric patients with T1D between the COVID-19 pre-pandemic and pandemic periods. We also compared glucose and HbA1c values in children who were newly diagnosed with T1D before and after the COVID-19 pandemic. The global incidence rate of T1D in the 2019 period was 19.73 per 100 000 children and 32.39 per 100 000 in the 2020 period. Compared with pre-COVID-19 pandemic, the number of worldwide pediatric new-onset T1D, DKA, and severe DKA during the first year of the COVID-19 pandemic increased by 9.5%, 25%, and 19.5%, respectively. Compared with pre-COVID-19 pandemic levels, the median glucose, and HbA1c values in newly diagnosed T1D children after the COVID-19 pandemic increased by 6.43% and 6.42%, respectively. The COVID-19 pandemic has significantly increased the risk of global pediatric new-onset T1D, DKA, and severe DKA. Moreover, higher glucose and HbA1c values in newly diagnosed T1D children after the COVID-19 pandemic mandates targeted measures to raise public and physician awareness.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus

INTRODUCTION

We explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes.

RESEARCH DESIGN AND METHODS

This observational study included all episodes of DKA from April 2014 to September 2020 in a UK tertiary care hospital. Data were collected on diabetes type, demographics, biochemical and clinical features at presentation, and DKA management.

RESULTS

From 786 consecutive DKA, 583 (75.9%) type 1 diabetes and 185 (24.1%) type 2 diabetes episodes were included in the final analysis. Those with type 2 diabetes were older and had more ethnic minority representation than those with type 1 diabetes. Intercurrent illness (39.8%) and suboptimal compliance (26.8%) were the two most common precipitating causes of DKA in both cohorts. Severity of DKA as assessed by pH, glucose and lactate at presentation was similar in both groups. Total insulin requirements and total DKA duration were the same (type 1 diabetes 13.9 units (9.1-21.9); type 2 diabetes 13.9 units (7.7-21.1); p=0.4638). However, people with type 2 diabetes had significantly longer hospital stay (type 1 diabetes: 3.0 days (1.7-6.1); type 2 diabetes: 11.0 days (5.0-23.1); p<0.0001).

CONCLUSIONS

In this population, a quarter of DKA episodes occurred in people with type 2 diabetes. DKA in type 2 diabetes presents at an older age and with greater representation from ethnic minorities. However, severity of presentation and DKA duration are similar in both type 1 and type 2 diabetes, suggesting that the same clinical management protocol is equally effective. People with type 2 diabetes have longer hospital admission.

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

BACKGROUND

One possible reason for increased mortality due to SARS-CoV-2 in patients with diabetes is from the complication of diabetic ketoacidosis (DKA).

OBJECTIVES

To re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA.

DESIGN

A systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.

METHODS

Electronic databases (Proquest, Medline, Embase, Pubmed, CINAHL, Wiley online library, Scopus and Nature) were searched from 1 December 2019 to 30 June 2021 in the English language using the following keywords alone or in combination: COVID-19 OR SARS-CoV-2 AND diabetic ketoacidosis OR DKA OR ketosis OR ketonemia OR hyperglycaemic emergency OR hyperglycaemic crisis. We included studies in adults and children of all ages in all healthcare settings. Binary logistic regression model was used to explore the effect of various demographic and biochemical parameters variables on patient's final treatment outcome (survival or death).

RESULTS

Of the 484 papers that were identified, 68 articles were included in the systematic review and meta-analysis (54 case report, 10 case series, and 4 cohort studies). Studies involving 639 DKA patients with confirmed SARS-CoV-2 [46 (7.2%) were children and 334 (52.3%) were adults] were analyzed. The median or mean patient age ranged from < 1 years to 66 years across studies. Most of the patients (n = 309, 48.3%) had pre-existing type 2 diabetes mellitus. The majority of the patients were male (n = 373, 58.4%) and belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity. The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399-638 mg/dl], 11.4% [IQR 9.9-13.5%], 7.16 [IQR 7.00-7.22], 10 mmol/l [IQR 6.9-13 mmol/l], and 24.5 mEq/l [18-29.2 mEq/l]; respectively. Mortality rate was [63/243, 25.9%], with a majority of death in patients of Hispanic ethnicity (n = 17, 27%; p = 0.001). The odd ratios of death were significantly high in patients with pre-existing diabetes mellitus type 2 [OR 5.24, 95% CI 2.07-15.19; p = 0.001], old age (≥ 60 years) [OR 3.29, 95% CI 1.38-7.91; p = 0.007], and male gender [OR 2.61, 95% CI 1.37-5.17; p = 0.004] compared to those who survived.

CONCLUSION

DKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [≥ 60 years old], male gender, BMI ≥ 30, blood glucose level > 1000 mg/dl, and anion gap ≥ 30 mEq/l.

A Fatal Case of Hypertriglyceridemia-Induced Acute Pancreatitis in a Patient With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) with coexisting hypertriglyceridemia-induced acute pancreatitis is a rare yet potentially life-threatening condition. This report describes a patient with no history of diabetes who presented with DKA and coexisting acute pancreatitis secondary to severe hypertriglyceridemia. The patient did not respond to standard DKA management or plasmapheresis, developed acute respiratory distress syndrome (ARDS), and eventually expired. 

Dijabetesna ketoacidoza kod bolesnika sa cerebrovaskularnim insultom - uzroci, mehanizmi, dijagnostika i naše smernice za terapiju

Although cerebrovascular disease may be a well recognised trigger for diabetic ketoacidosis (DKA), literature data on the precise mechanisms, characteristics, or treatment guidelines are rare. The risk of developing an ischemic stroke is doubled in adults with diabetes compared to people with normal glucose metabolism. It is important to point out that even children with DKA have a significantly increased risk of cerebrovascular insult and that they can have a stroke with a frequency of about 10%. Given the significant overlap of symptoms between these two diseases, it can be assumed that attributing DKA symptoms as a manifestation of stroke is not uncommon, especially in elderly and less communicative patients. In addition, pH, bicarbonate concentration, and anion gap are not routinely measured in all diabetics suffering from stroke, at least not in secondary health institutions.Children who develop cerebrovascular stroke during DKA often at the beginning have a preserved consciousness or only mild confusion or lethargy. After a few hours, with the institution of therapy, however, loss of consciousness may occur accompanied by signs of increased intracranial pressure. It was previously thought that the cause was too fast fluid replacement. Recent data suggest that reperfusion injury may be a more likely mechanism. Although most of these studies relate to younger individuals with ketoacidosis, it is clear that at least some of them may be operative in adult DKA. Literature therapeutic guidelines for adult diabetics with stroke-related diabetic ketoacidosis are almost lacking, although it is clear that they could not be the same as those utilised in population with normal glucose metabolism. In this paper, we have tried to define our treatment guidelines for these particular patients.

Investigating Ketone Bodies as Immunometabolic Countermeasures against Respiratory Viral Infections

Respiratory viral infections remain a scourge, with seasonal influenza infecting millions and killing many thousands annually and viral pandemics, such as COVID-19, recurring every decade. Age, cardiovascular disease, and diabetes mellitus are risk factors for severe disease and death from viral infection. Immunometabolic therapies for these populations hold promise to reduce the risks of death and disability. Such interventions have pleiotropic effects that might not only target the virus itself but also enhance supportive care to reduce cardiopulmonary complications, improve cognitive resilience, and facilitate functional recovery. Ketone bodies are endogenous metabolites that maintain cellular energy but also feature drug-like signaling activities that affect immune activity, metabolism, and epigenetics. Here, we provide an overview of ketone body biology relevant to respiratory viral infection, focusing on influenza A and severe acute respiratory syndrome (SARS)-CoV-2, and discuss the opportunities, risks, and research gaps in the study of exogenous ketone bodies as novel immunometabolic interventions in these diseases.

Clinical profiles, outcomes and risk factors among type 2 diabetic inpatients with diabetic ketoacidosis and hyperglycemic hyperosmolar state: a hospital-based analysis over a 6-year period

OBJECTIVE

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most common hyperglycemic emergencies (HEs) associated with diabetes mellitus. Individuals with HEs can present with combined features of DKA and HHS. The objective of this study is to assess the clinical characteristics, therapeutic outcomes, and associated predisposing factors of type 2 diabetic patients with isolated or combined HEs in China.

METHODS

We performed a retrospective analysis of 158 patients with type 2 diabetes (T2DM), complicated with DKA, HHS, or DKA combined with HHS (DKA-HHS) in Shanghai Tongji Hospital, China from 2010 to 2015. Admission clinical features, therapeutic approaches and treatment outcomes of those patients were extracted and analyzed.

RESULTS

Of the 158 patients with T2DM, 65 (41.1%) patients were DKA, 74 (46.8%) were HHS, and 19 (12.0%) were DKA-HHS. The most common precipitants were infections (111, 70.3%), newly diagnosed diabetes (28,17.7%) and non-compliance to medications (9, 5.7%). DKA patients were divided into mild, moderate and severe group, based on arterial blood gas. Spearman correlation analysis revealed that C-reaction protein (CRP) was positively correlated with severity of DKA, whereas age and fasting C peptide were inversely correlated with severity of DKA (P < 0.05). The mortality was 10.8% (17/158) in total and 21.6% (16/74) in the HHS group, 5.9% (1/17) in DKA-HHS. Spearman correlation analysis indicated that death in patients with HHS was positively correlated to effective plasma osmolality (EPO), renal function indicators and hepatic enzymes, while inversely associated with the continuous subcutaneous insulin infusion (CSII) therapy. Logistic regression analysis suggested that elevated blood urea nitrogen (BUN) on admission was an independent predisposing factor of mortality in HHS, while CSII might be a protective factor for patients with HHS. Furthermore, the receiver-operating characteristic (ROC) curve analysis indicated that BUN had the largest area under the ROC curves for predicting death in patients with HHS.

CONCLUSIONS

Our findings showed elevated CRP and decreased fasting C-peptide might serve as indicator for severe DKA. Elevated BUN might be an independent predictor of mortality in patients with HHS, whereas CSII might be a protective factor against death in HHS.

Diabetic Ketoacidosis: Clinical Characteristics and Precipitating Factors

Introduction: Diabetic ketoacidosis (DKA) is a complication of hyperglycemia. Through this study we plan to study the clinical features of DKA and precipitating factors responsible for DKA in type 1 and type 2 diabetes.

Methods: This cross-sectional observational study was conducted in the emergency department of a tertiary care hospital in Sukkur, Pakistan from August 2019 to February 2020. Symptoms and precipitating factors were noted in a self-structured questionnaire.

Results: Out of 71 patients, 19 (26.7%) patients had type 1 diabetes mellitus and 52 (73.3%) patients had type 2 diabetes mellitus. The most common clinical symptom was nausea and vomiting (57.7%), followed by pain in abdomen (42.2%) and dehydration (42.2%). We found that the most common precipitating factors were infections (69.0%) and non-compliance to treatment (53.5%). Among various infections, people commonly presented with pneumonia (38.7%) and urinary tract infection (30.6%).

Conclusion: Diabetic ketoacidosis presents with vague symptoms such as nausea, vomiting, and pain in abdomen. Characteristic findings of DKA such as Kussmaul breathing was present in limited patients. Infections in diabetic patients should be carefully monitored as they are the most common precipitating factors for DKA.

Level of awareness of diabetic ketoacidosis among diabetes mellitus patients in Riyadh

Background:

Diabetic ketoacidosis (DKA) is considered to be a serious acute life-menacing complication of diabetes type (1) and type (2). The study aims to assess the level of awareness regarding DKA among diabetic patients in the Riyadh population.

Methodology:

The study is an institution-based cross-sectional study with a sample size of 150 participants. The participants are chosen through systemic random sampling, who have type (1) or type (2) diabetes mellitus patients and are 18–35 years of age. The medical personnel were excluded from the study. A self-administered, precoded, and pretested questionnaire was developed especially for this study after consulting literature and epidemiologists containing data about the risk factor, management, and complication. Data were analyzed using (SPSS). A P value of less than 0.05 was considered significant.

Results:

38.67% (58) participants have poor awareness regarding complications, 67.34% (101) have poor knowledge regarding management, and 6% (9) participants have a good knowledge, 38% (57) participants have poor knowledge regarding risk factors and 30% (45) of the participants have good awareness. The relation between having a first degree relative with diabetes and awareness regarding management is significant with a P value of 0.022; 73% (110) of the participants had no relatives with diabetes mellitus and 71% (79) had a poor level of awareness regarding the management of DKA. However, 55% (22) of respondents who had relatives with diabetes mellitus also had a poor level of awareness regarding treatment.

Conclusion:

The majority of the participants had a poor level of awareness. There is a relationship between having a first-degree relative with diabetic mellitus and the level of awareness regarding DKA.

Precipitating Risk Factors, Clinical Presentation, and Outcome of Diabetic Ketoacidosis in Patients with Type 1 Diabetes

Introduction

Over the past few years, there have been drastic advancements in the management of type 1 and 2 diabetes mellitus (DM). Prevention of complications is a prime concern of all physicians dealing with DM. However, whether or not these interventions have helped in reducing the incidence of diabetic ketoacidosis (DKA) in patients with type 1 DM, is still an unanswered question. The aim of this study is to assess the clinical pattern of DKA, evaluate its outcomes, and study the predictors of outcome.

Methods

The study was conducted as a prospective, observational one in the department of medicine of a tertiary care hospital from July-December 2018. Patients of type 1 DM presenting in the emergency department with DKA were evaluated for their predisposing factors, clinical presentation, biochemical parameters, rate of mortality, and predictors of mortality. Data was processed through and analyzed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY).

Results

The common clinical presentations include severe vomiting (32.2%), abdominal pain (27.9%), and depressed mental state (DMS) (26.8%). Infections (36.5%) and inadequate insulin dose (22.5%) were frequently seen as the predisposing factors. In one-fourth of the patients, this episode of DKA was the first presentation of DM (26.8%). The rate of mortality was 23.6%. The predictors of mortality included DMS, markedly low pH and serum bicarbonate, and high serum potassium at the time of presentation, random blood sugar >300 mg/dL and urine positive for ketones even after 12 hours of medical intervention, >50 international units (IU) insulin requirement within the first 12 hours, >6L fluid replenished within the first 24 hours, and new onset of fever within the first 24 hours.

Conclusion

The clinical presentation of DKA is not stark and vague signs such as generalized fatigue, nausea vomiting, abdominal pain, and DMS should raise suspicion. Underlying infections and inadequate insulin regimen predispose to acute DKA attack. Rate of mortality is high in these patients. Morality may be predicted by various clinical and biochemical parameters.

Correlation of acidosis-adjusted potassium level and cardiovascular outcomes in diabetic ketoacidosis: a systematic review

BACKGROUND

During the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events.

OBJECTIVE

To assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA.

METHODOLOGY

Seven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale.

RESULTS

Forty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level.

CONCLUSION

The evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.

Guidelines and controversies in the management of diabetic ketoacidosis – A mini-review

Diabetic ketoacidosis (DKA) is a complication seen in patients with both type 1 and type 2 diabetes. Due to its large, growing economic impact with associated morbidity, closer look at proper management is important. Factors involved in appropriate management involves fluid resuscitation, insulin regimen, and electrolyte replacement including types of fluid and insulin treatment. The caveat with generalized protocol is application to special populations such as renal or heart failure patients the sequelae of complications due to pathophysiology of the disease processes. This leads to complications and longer length of stay in the hospital, therefore, possibly increased cost and resource utilization during the hospitalization. This review takes a closer look at current guidelines of DKA management and resource utilization, the drawbacks of current management protocols and the cost associated with it. Therefore, a need for amendment to existing protocol or initiation of a newer guideline that properly manages DKA should incorporate special populations and appropriate regimen of fluid resuscitation, insulin therapy and electrolyte management.

Correlation between the outcomes and severity of diabetic ketoacidosis: A retrospective pilot study

Introduction

Diabetic ketoacidosis (DKA) is a serious acute metabolic complication of diabetes mellitus (DM). It is classified into mild, moderate, and severe based on severity as per the American Diabetes Association (ADA) guidelines. There are limited data on the correlation between the severity of DKA and its outcomes using this classification system. The aim is to study the correlation between the outcomes and severity of DKA in a tertiary care center in India.

Methodology

In this retrospective pilot study, 1527 patients with DM were identified over a span of 3 years, of which 63 had a discharge diagnosis of DKA and 37 fulfilled the ADA criteria for DKA. Following inclusion details on clinical parameters and outcomes of patients with mild, moderate, and severe DKA were compared.

Results

Mild, moderate, and severe DKA accounted for 8%, 41%, and 51% of the patients, respectively. Intensive Care Unit (ICU) care was required in 6.7% and 47.4% of those with moderate and severe DKA, respectively. Invasive ventilation (IV) was required in 47% (9) of those with severe DKA only. The mortality rates were 13.3% and 26% among those with moderate and severe DKA. The mean expenditure was ₹29,000, ₹30,000, and ₹64,000 among those with mild, moderate, and severe DKA, respectively.

Conclusions

The ADA classification of severity of DKA correlates well with the duration of inhospital stay, costs of care, requirement of ICU care, need for IV or non-IV, and mortality. This suggests that this classification system could be a valuable tool in predicting outcomes.

The management of diabetic ketoacidosis at a rural regional hospital in KwaZulu-Natal

Background

Diabetic ketoacidosis (DKA) is a biochemical triad of hyperglycaemia, ketoacidosis and ketonaemia and one of the potentially life-threatening acute metabolic complications of diabetes mellitus. This study aimed at describing the clinical profile of patients presenting with DKA to a busy rural regional hospital in KwaZulu-Natal.

Methods

A retrospective review of clinical notes of patients presenting with DKA to the Emergency Department was performed over a 10-month period. Data included patients’ demographic profile, clinical presentation, precipitating factors, comorbidities, biochemical profile, length of hospital stay and outcome.

Results

One hundred and five black South African patients above the age of 12 years were included in the study. Sixty-four (60.95%) patients had type 1 diabetes mellitus (T1DM) and 41 (39.05%) patients had type 2 diabetes mellitus (T2DM). Patients with T2DM were significantly older than those with T1DM (52.1 ± 12.4 years vs. 24.4 ± 9.5 years, p < 0.0001). The acute precipitant was identified in 68 (64.76%) cases with the commonest precipitant in T1DM patients being poor adherence to treatment, whereas in T2DM, the most common precipitant was infection. Nausea and vomiting were the most common presenting symptoms with the majority of patients presenting with non-specific symptoms. Fifty-seven (54.29%) cases had pre-existing comorbidities, with higher prevalence in T2DM than T1DM patients. Glycated haemoglobin was severely elevated in the majority of patients. Patients remained hospitalised for an average of 8.9 ± 7.5 days. The mortality rate was 17.14%, and 12 of the 18 deaths occurred in patients with T2DM.

Conclusion

The prevalence of DKA was higher in patients with T1DM and those with pre-existing comorbidities. The mortality rate remains alarmingly high in older patients with T2DM.

Type 2 diabetes, depressive symptoms and disability over a 15-year follow-up period in older Mexican Americans living in the southwestern United States

AIMS

To evaluate how depression and diabetes severity impact disability progression among Mexican Americans over a 15-year period.

METHODS

We used seven waves of the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE). Primary disability outcomes included the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales. Explanatory variables included time since diagnosis with diabetes (no type 2 diabetes, 1-10, 11-20, 21+), an indicator of disease severity, and depression. Longitudinal generalized estimating equation models were used to estimate the relationship between time since diabetes diagnosis, depressive symptoms and ADL and IADL disability progression over a 15-year time period.

RESULTS

Years since diabetes diagnosis was associated with more rapid ADL and IADL disability progression compared to those without type 2 diabetes. Depression accelerated the disabling process in participants who were diagnosed with diabetes 11years or more years ago.

CONCLUSIONS

Longer duration of diabetes and greater symptoms of depression increase vulnerability for disability among older Mexican American adults.

Management of diabetic ketosis and ketoacidosis with intramuscular regular insulin in a low-resource family medicine setting

Background:

India is facing an epidemic of diabetes mellitus (DM). Effective management of complications of DM is a challenge in resource-poor areas of India. This study addresses the need to explore low-cost methods to manage diabetic ketosis (DK) and diabetic ketoacidosis (DKA).

Objectives:

To demonstrate the use of intramuscular (IM) regular insulin as a safe alternative method to control DK and DKA in a family practice setting.

Materials and Methods:

A retrospective chart review was done for 34 patients admitted with DK and DKA in a family medicine unit for the urban poor over 5 years. Data on age, sex, precipitating factors, blood pressure, number of days of hospitalization, amount of insulin, and time required to control blood glucose (BG) and to correct acidosis were entered into EpiData version 3.1 and analyzed using SPSS software version 17.

Results:

Administration of IM regular insulin was effective in reducing the BG to < 250 mg/dL in patients with DK and DKA. The mean time required for this in the ketosis group was 3.8 h and in the ketoacidosis group was 3.9 h. The mean amount of insulin required for correction of acidosis in the ketoacidosis group was 72.3 units and the mean time to achieve this was 33 h. Of the 34 patients, only one in the ketoacidosis group had hypoglycemia. There was no fatality or referral of any patient.

Conclusion:

This study demonstrates that IM regular insulin is a safe alternative method in managing DK and DKA in a family medicine setting.

Platelet-to-Lymphocyte Ratio: A Novel Prognostic Factor for Prediction of 90-day Outcomes in Critically Ill Patients With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and the novel systemic inflammation marker platelet-to-lymphocyte ratio (PLR) may be associated with clinical outcome in patients with DKA. This study aimed to investigate the utility of PLR in predicting 90-day clinical outcomes in patients with DKA. Patient data exacted from the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC II) database was analyzed. A cutoff value for PLR of 267.67 was determined using Youden index (P < 0.05) and used to categorize subjects into a high PLR group and a low PLR group. The hazard ratios (HRs) and 95% confidence intervals (CIs) for DKA were calculated across PLR. Clinical outcomes in our study were defined as intensive care unit (ICU) 90-day readmission and all-cause mortality. A total of 278 ICU admissions were enrolled and stratified by cutoff value of PLR. The incidence of readmission and mortality was 17.8% in the high PLR group, significantly higher than 7.4% in the low PLR group. In the multivariable model, after adjusting for known confounding variables including clinical parameters, comorbidities, laboratory parameters, the HRs for DKA were 2.573 (95% CI 1.239-5.345; P = 0.011), 2.648 (95% CI 1.269-5.527; P = 0.009), and 2.650 (95% CI 1.114-6.306; P = 0.028), respectively. The Kaplan-Meier survival curve showed that a high PLR level was associated with a higher risk for 90-day outcomes in patients with DKA. The authors report that higher PLR presents a higher risk for 90-day incidence of readmission and mortality in patients with DKA. It appears to be a novel independent predictor of 90-day outcomes in critically ill DKA patients in ICU units.