Outcomes associated with a variable rate insulin infusion diabetic ketoacidosis protocol

AIMS

To relate adverse events with glucose correction rates in diabetic ketoacidosis (DKA) using variable rate intravenous insulin-infusions (VRIII).

METHODS

Retrospective, observational study in adults with DKA who received insulin infusions between 2012 and 2017 at St Vincent's Hospital, Melbourne. Early correction of hyperglycaemia (<10 mmol/L) was evaluated for association with hypoglycaemia (<4.0 mmol/L), hypokalaemia (potassium <3.3 mmol/L) and clinical outcomes via regression analysis.

RESULTS

The study involved 97 patients, with 93 % having type 1 diabetes. The mean age was 38 years, 47 % were women and 35 % were admitted to intensive care. Hypoglycaemia rates during 12 and 24 h of treatment were 6.2 % and 8.2 %, respectively with 58 % of patients recording their first BGL <10 mmol/L within 12 h and 88 % within 24 h. Ketone clearance time averaged at 15.6 h. Hyperglycaemia correction rates to <10 mmol/L were not different in those with/without hypoglycaemia at 12/24 h, in multivariate analysis including admission BGL. Hypokalaemia occurred in 40.2 % of patients and was associated with lower pH but not BGL correction rates.

CONCLUSION

The VRIII protocol achieved early hyperglycaemia correction and ketoacidosis reversal with low hypoglycaemia risk. However, high hypokalaemia rates suggest the need for aggressive potassium replacement, especially in markedly acidotic patients.

Prevalence of hyperglycaemia without previously recognised diabetes mellitus in the emergency department and subsequent management: a retrospective cross-sectional study

BACKGROUND

Australian hospital data on hyperglycaemia without previously known diabetes are lacking.

AIMS

To determine the prevalence of hyperglycaemia without previously recognised diabetes among all patients screened in the emergency department (ED). Secondary aims are to describe the extent of haemoglobin A1c testing for evaluation of new diabetes, adequate glucose monitoring, treatment of significant hyperglycaemia and documented follow-up plans.

METHODS

Patients presenting to ED at the Alfred (tertiary hospital in Melbourne) have undergone screening random plasma glucose (RPG) with their first plasma biochemistry since 2015. Of the 16 268 adults screened from July to December 2015, a retrospective, cross-sectional study was undertaken evaluating those with hyperglycaemia (RPG >7.8 mmol/L) but without previously recognised diabetes as determined from coding data. After patient records were reviewed to correct for coding errors, a nested cohort of 200 such patients were further evaluated. Glucose monitoring was deemed adequate if undertaken for ≥48 h. Significant hyperglycaemia (RPG >11 mmol/L) was considered appropriately treated if insulin/hypoglycaemic agents were prescribed. Documented follow-up plans were acceptable if found in the discharge summary.

RESULTS

Among all patients screened, 1178 had hyperglycaemia without coded diabetes. After adjusting for coding errors, the prevalence was 5.2%. Within the nested cohort, only 7.5% had a follow-up haemoglobin A1c ordered, 9.5% underwent adequate glucose monitoring, 6.5% had appropriate treatment of significant hyperglycaemia and 2% had documentation of a follow-up plan.

CONCLUSIONS

Hyperglycaemia without previously recognised diabetes is commonly seen and justifies ED screening. However, management of newly detected hyperglycaemia in these patients is suboptimal and requires improvement.

SGLT2 Inhibitors Increase the Risk of Diabetic Ketoacidosis Developing in the Community and During Hospital Admission

CONTEXT

Diabetic ketoacidosis (DKA) has been associated with the use of sodium glucose cotransporter 2 inhibitors (SGLT2is).

OBJECTIVE

To determine the incidence, characteristics, and outcomes of DKA in SGLT2i users vs nonusers with type 2 diabetes.

DESIGN

Retrospective, multicenter, controlled cohort study.

SETTING

All public hospitals in Melbourne and Geelong (combined population of 5 million), Australia, from 1 September 2015 to 31 October 2017.

PATIENTS

Consecutive cases of DKA that developed in the community, or during the course of hospital admission, in patients with type 2 diabetes.

MAIN OUTCOME MEASURES

In SGLT2i users vs nonusers: (i) OR of DKA developing during hospital admission, and (ii) incidence of DKA.

RESULTS

There were 162 cases of DKA (37 SGLT2i users and 125 non-SGLT2i users) with a physician-adjudicated diagnosis of type 2 diabetes. Of these, DKA developed during the course of inpatient admission in 14 (38%) SGLT2i users vs 2 (2%) non-SGLT2i users (OR, 37.4; 95% CI, 8.0 to 175.9; P < 0.0001). The incidence of DKA was 1.02 per 1000 (95% CI, 0.74 to 1.41 per 1000) in SGLT2i users vs 0.69 per 1000 (95% CI, 0.58 to 0.82 per 1000) in non-SGLT2i users (OR, 1.48; 95% CI, 1.02 to 2.15; P = 0.037). Fifteen SGLT2i users (41%) had peak blood glucose <250 mg/dL (14 mmol/L) compared with one (0.8%) non-SGLT2i user (P < 0.001).

CONCLUSIONS

SGLT2i users were more likely to develop DKA as an inpatient compared with non-SGLT2i users. SGLT2i use was associated with a small but significant increased risk of DKA.

SAT-130 Prevalence and Management of Hyperglycemia in Patients without Previously Recognised Diabetes Mellitus Presenting to the Emergency Department: A Retrospective Cross-Sectional Study

Background: Internationally, the prevalence of hyperglycemia among patients without previously known diabetes in the hospital setting is 7-12%, but Australian data are lacking (1,2). It is important to recognise and follow up hyperglycemia since it is associated with increased mortality and may signify a potential diagnosis of underlying diabetes (1,3). Objectives: To determine the prevalence of hyperglycemia without previously recognised diabetes among all patients screened in the Emergency Department (ED). Secondary aims were to describe the extent of further evaluation for new diabetes via HbA1c testing, adequate glucose monitoring, treatment of significant inpatient hyperglycemia and documented follow-up plans. Methods: Since 2015, all presentations to the ED at a tertiary hospital in Melbourne, Australia underwent screening random plasma glucose (RPG) along with their first plasma biochemistry. RPG in all adult ED presentations was evaluated in a retrospective, cross-sectional study from July to December, 2015. All subjects with hyperglycemia (RPG >7.8 mmol/L) were studied. Pre-existing diabetes was excluded using coding data. Medical records were reviewed to correct for coding errors. A random nested cohort of 200 patients without previously recognised diabetes was further evaluated. Blood glucose monitoring was adequate if undertaken for ≥48 hours. RPG >11 mmol/L was considered significant hyperglycemia and was defined as being adequately treated if supplemental/regular insulin and/or other hypoglycemic agents were charted. Planning of follow-up was considered adequate if hyperglycemia was recognised and a management plan documented in the discharge summary. Results: Prevalence of hyperglycemia in patients without previously recognised diabetes among all patients screened in ED was 5.2% (845/16,268). Of these, 79% required hospital admission and significant hyperglycemia occurred in 15.5%. Within the nested cohort, only 7.5% had follow-up HbA1c. New diabetes (HbA1c ≥6.5% + RPG >11mmol/L) was diagnosed in 20% (3/15) undergoing HbA1c testing. Glucose was adequately monitored in only 9.5%. Appropriate treatment of significant hyperglycemia occurred in only 6.5%. Documentation of a follow-up plan was evident in only 2%. Conclusion: Hyperglycemia is common among patients without previously recognised diabetes presenting to ED. Further evaluation with an HbA1c for new diabetes, performing glucose monitoring, treating significant hyperglycemia in hospital and planning follow-up were suboptimal and require improvement. This is a lost opportunity to diagnose diabetes in those at risk. Reference: (1) Umpierrez et al. J Clin Endocrinol Metab. 2002; 87: 978-82, (2) George et al. Diabetic Med 2005; 22: 1766‐69, (3) Krebs et al. NZ Med J 2000; 113: 379‐81.