Hyperglycemic crises in adult patients with diabetes

Metabolic acidosis with elevated anion gap and euglycemic ketoacidosis in pregnant and postpartum women with severe Covid-19

BACKGROUND/OBJECTIVES

Pregnant and postpartum women have a higher risk for developing severe Covid-19 and other clinical and obstetric complications. This study aims to evaluate the frequency of metabolic acidosis with elevated anion gap and describe a case series of euglycemic ketoacidosis (EKA) in pregnant and postpartum women with severe confirmed or suspected Covid-19.

MATERIALS AND METHODS

Observational retrospective study carried in a reference intensive care unit from May 2020 to June 2022. Cases were confirmed with positive RT-PCR or rapid antigen test. Cases with compatible clinical and radiologic findings were also included. Ketoacidosis was defined as the presence of metabolic acidosis with high anion gap (bicarbonate < 15 mEq/L and AG > 10 mEq/L) and ketonuria (2+ or more in urine test). Statistical analyses were made with R software.

RESULTS

Of 101 admissions, 61 (60.4%) presented metabolic acidosis with high anion gap. The median age was 29 years, and most were in the third trimester. Evolution to invasive mechanical ventilation (54.0%) and obstetric complications (78.0%) were frequent. The prevalence of metabolic acidosis with high anion gap and absence of hyperlactatemia was of 43.6% (44/101). Six (5.94%) women met the criteria for EKA. Despite severity, there were no deaths.

CONCLUSIONS

The prevalence of metabolic acidosis and EKA in pregnant and postpartum women with severe Covid-19 was high. This condition should be routinely, so it can be promptly treated.

Experimental and computational analysis of benzothiophene as a selective inhibitors of diabetes mellitus

Diabetes mellitus results in chronic hyperglycemia, affecting more than one hundred million people over the world. To treat diabetes mellitus, novel benzothiophene-derived thiadiazole analogues (1-17) were synthesized to biological assess their potential as lead inhibitors of both diabetic enzymes (α-amylase and α-glucosidase). These compounds showed quite remarkable potency against both enzymes and emerged as anti-diabetic agents. As a reference for their biological assessment, acarbose (5.90 ± 0.30 μM, 6.50 ± 1.80 μM) were used and in comparison to it analogue 3 having IC50 of 4.20 ± 0.50 μM, 4.90 ± 1.50 μM, 6 with IC50 of 3.10 ± 1.20 μM, 4.10 ± 0.80 μM, 10 with IC50 of 5.20 ± 1.20 μM, 6.10 ± 2.10 μM and 16 having IC50 of 3.90 ± 2.20 μM, 4.10 ± 1.20 μM emerged as most active analogues among the synthesized derivatives. Versatile attached functionalities such as CF3, F, OH and Cl bind with the target proteins in order to inhibit their normal activity or function. Binding potency (interactive properties) of the leading compounds was also revealed under molecular docking. ADME analysis further unveiled that the potent compounds exhibit drug properties. Moreover, reactivity of these analogues with leading potential was also explored via density functional theory (DFT), revealing their molecular electrostatic potential, electrophilic, nucleophilic, HOMO and LUMO sites.

Early Versus Late Administration of Long-Acting Insulin in Adult Diabetic Ketoacidosis

BACKGROUND

Evidence is inconclusive if early administration of subcutaneous (SQ) long-acting insulin (LAI) in management of diabetic ketoacidosis (DKA) improves outcomes.

OBJECTIVE

This study compares early versus late administration of SQ LAI in time to DKA resolution.

METHODS

This single-center, retrospective study included patients with DKA who received ≥12 hours of continuous intravenous insulin (CIVI) with LAI overlap. Patients were compared based on LAI administration time to CIVI initiation: Early (<12 hours) versus Late (≥12 hours). The DKA resolution is defined as blood glucose < 200 mg/dL and 2 of the following: anion gap < 12 mEq/L, pH > 7.35, or serum carbon dioxide >15 mEq/L. Outcomes included time to DKA resolution, length of stay (LOS), CIVI duration, and adverse events.

RESULTS

A total of 27 patients were included in each group. Baseline characteristics were similar between both groups. There was no difference in time to DKA resolution, Early = 17.6 (13.9-26.8) hours versus Late = 19.2 (17.1-32.1) hours, P = 0.16. The Early group had shorter CIVI duration (Early = 19.5 ± 10.3 hours vs Late = 25.6 ± 8.4 hours, P = 0.02) and received less intravenous (IV) fluids in the first 36 hours (Early = 4.04 ± 2.12 L vs Late = 5.85 ± 2.24 L, P = 0.004). No differences were identified with adverse events, including hypoglycemia, or LOS.

CONCLUSION AND RELEVANCE

Administration of SQ LAI < 12 hours did not decrease time to DKA resolution or LOS. Patients in the Early group had received a lower dose of LAI, shorter duration of CIVI infusion, and required less IV fluids within 36 hours of admission. This study supports the need for further research to determine the potential benefits of administering SQ insulin early in managing DKA.

Impact of Continuous Glucose Monitoring Versus Blood Glucose Monitoring to Support a Carbohydrate-Restricted Nutrition Intervention in People with Type 2 Diabetes

Introduction: Low- and very-low-carbohydrate eating patterns, including ketogenic eating, can reduce glycated hemoglobin (HbA1c) in people with type 2 diabetes (T2D). Continuous glucose monitoring (CGM) has also been shown to improve glycemic outcomes, such as time in range (TIR; % time with glucose 70-180 mg/dL), more than blood glucose monitoring (BGM). CGM-guided nutrition interventions are sparse. The primary objective of this study was to compare differences in change in TIR when people with T2D used either CGM or BGM to guide dietary intake and medication management during a medically supervised ketogenic diet program (MSKDP) delivered via continuous remote care. Methods: IGNITE (Impact of Glucose moNitoring and nutrItion on Time in rangE) study participants were randomized to use CGM (n = 81) or BGM (n = 82) as part of a MSKDP. Participants and their care team used CGM and BGM data to support dietary choices and medication management. Glycemia, medication use, ketones, dietary intake, and weight were assessed at baseline (Base), month 1 (M1), and month 3 (M3); differences between arms and timepoints were evaluated. Results: Adults (n = 163) with a mean (standard deviation) T2D duration of 9.7 (7.7) years and HbA1c of 8.1% (1.2%) participated. TIR improved from Base to M3, 61-89% for CGM and 63%-85% for BGM (P < 0.001), with no difference in change between arms (P = 0.26). Additional CGM metrics also improved by M1, and improvements were sustained through M3. HbA1c decreased by ≥1.5% from Base to M3 for both CGM and BGM arms (P < 0.001). Diabetes medications were de-intensified based on change in medication effect scores from Base to M3 (P < 0.001). Total energy and carbohydrate intake decreased (P < 0.001), and participants in both arms lost clinically significant weight (P < 0.001). Conclusion: Both the CGM and BGM arms saw similar and significant improvements in glycemia and other diabetes-related outcomes during this MSKDP. Additional CGM-guided nutrition intervention research is needed.

Islet autoantibodies in Thai individuals diagnosed with type 1 diabetes before 30 years of age: a large multicentre nationwide study

AIMS/HYPOTHESIS

Type 1 diabetes is categorised into autoantibody positive and autoantibody negative. Most type 1 diabetes research has focused on European populations, leaving a gap in understanding in relation to other ethnic groups, including Thai populations. This lack of data is significant given Thailand's poor prevention and therapeutic management strategies. We aimed to investigate the frequency and distribution of islet autoantibodies among Thai individuals with long-standing type 1 diabetes diagnosed before the age of 30 years.

METHODS

We conducted a nationwide population-based study involving 48 hospitals in Thailand from May 2020 to September 2023, enrolling 953 participants. Demographic and clinical characteristics of individuals with autoantibody-positive and -negative type 1 diabetes were analysed. The autoantibodies GAD65, IA-2 and ZnT8 were measured using ELISA. A random C-peptide level was detected by electrochemiluminescence immunoassay.

RESULTS

Thai individuals with autoantibody-negative type 1 diabetes comprised 34.2% of the population. Among all individuals, the frequency of GAD65, IA-2 and ZnT8 was 56%, 37% and 33%, respectively. Autoantibody-negative individuals with type 1 diabetes were older at diagnosis, had higher BMI and had higher random C-peptide levels compared with autoantibody-positive individuals with type 1 diabetes. Female individuals had a higher prevalence of type 1 diabetes than male individuals (58% vs 42%; p=1.531 × 10-5). The southern region of Thailand exhibited a distinct pattern of autoantibody frequency compared with other regions (p=0.0001561).

CONCLUSIONS/INTERPRETATION

The frequency, distribution and characteristics of autoantibody-positive and -negative long-standing type 1 diabetes in Thailand showed uniqueness from other populations. This provides insight into the disease that may have implications for type 1 diabetes prediction, treatment and pathogenesis, especially in the Southeast Asian population.

Metabolic effects of 3-hydroxybutyrate infusion in individuals with type 1 diabetes compared with healthy control participants: a randomised crossover trial showing intact feedback suppression of lipolysis

AIMS/HYPOTHESIS

Diabetic ketoacidosis remains a severe complication in type 1 diabetes, arising from insufficient insulin levels and accelerated lipolytic rate, leading to increased β-oxidation of NEFA and ketone body production in the liver. The ketone body 3-hydroxybutyrate (3-OHB) inhibits lipolysis in healthy individuals. The current study aimed to test whether this feedback suppression of lipolysis by 3-OHB is disrupted in individuals with type 1 diabetes.

METHODS

We used a single-blind, randomised, crossover design to study ten men diagnosed with type 1 diabetes and ten healthy control participants. Eligibility criteria were male sex, age ≥18 years, BMI of 19-26 kg/m2 and no severe comorbidities/diseases. Following an overnight fast, each participant received two 3 h i.v. infusions: (i) sodium-D/L-3-OHB and (ii) iso-osmolar saline (NaCl), separated by a 1 h washout period. The order of the two interventions was assigned by randomisation for each participant. Participants were blinded to the allocation throughout the study day, but investigators were aware of the assigned intervention order. We evaluated the lipolytic rate and glucose turnover using [9,10-3H]palmitate and [3-3H]glucose tracers. Additionally, adipose tissue signalling was quantified using western blotting techniques in subcutaneous abdominal adipose tissue biopsies. The primary endpoint measure was palmitate flux (lipolytic rate).

RESULTS

During the infusion of 3-OHB, the D/L-3-OHB blood concentrations increased to 3.3 ± 0.7 mmol/l in participants with type 1 diabetes compared with 2.9 ± 0.5 mmol/l in control participants (p=0.03). The infusion effectively suppressed the lipolytic rates by more than 50% (p<0.001) and reduced circulating NEFA by approximately 0.5 mmol/l (p<0.001) compared with NaCl in both participants with type 1 diabetes and control participants. In adipose tissue, 3-OHB reduced protein kinase A phosphorylation of perilipin (p<0.001) and hormone-sensitive lipase phosphorylation at Ser660 (p<0.001) and Ser563 (p<0.01) similarly in participants with type 1 diabetes and control participants. Indices of glucose metabolism remained unaffected throughout in both groups.

CONCLUSIONS/INTERPRETATION

Our findings indicate that, in individuals with type 1 diabetes, the suppression of lipolysis, blood NEFA concentrations and adipose tissue signalling activity in response to 3-OHB remains intact compared with healthy control participants. These findings imply that derailment of receptor signalling by 3-OHB is unlikely to be involved in the development of diabetic ketoacidosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04656236 FUNDING: Open access funding provided by Aarhus Universitet. This study was supported by the Novo Nordisk Foundation (NNF19OC0058872) and the Health Research Foundation of Central Denmark Region.

Prevalence of in-hospital mortality among adult patients with diabetic ketoacidosis in Ethiopia: a systematic review and meta-analysis of observational studies

Background

Diabetic ketoacidosis (DKA) is one of the most common life-threatening acute metabolic complications of diabetes, typically associated with disability, mortality, and significant health costs for all societies. In Ethiopia, available studies on in-hospital mortality rates of people living with DKA have shown high variability. Therefore, this systematic review and meta-analysis aims to summarize and provide quantitative estimates of the prevalence of in-hospital mortality among adult people living with DKA treated in Ethiopian hospitals.

Methodology

A systematic literature search was conducted using MEDLINE, Embase, Google Scholar, Web of Science, and Africa-specific databases. Data were extracted in a structured format prepared using Microsoft Excel. The extracted data were exported to R software Version 4.3.0 for analysis. The I2 test was used to check the heterogeneity between primary studies with a corresponding 95% confidence interval (CI). Based on the test result, a random-effects meta-analysis model was used to estimate Der Simonian and Laird's pooled effect on in-hospital mortality.

Result

The review included a total of 5 primary studies. The pooled prevalence of in-hospital mortality among people living with DKA who received treatment in Ethiopia hospitals was found to be 7% (95% CI: 1-12). Most of the included studies reported that nonadherence to insulin treatment followed by infection was the most common triggering factor for the development of DKA.

Conclusion

The prevalence of in-hospital mortality among people living with DKA was found to be 7%. This figure is unacceptably high compared to other published reports. Nonadherence to insulin treatment or antidiabetic medication and infection were identified as precipitating factors for developing DKA. Therefore, measures must be taken to improve medication adherence and decrease in-hospital mortality by providing ongoing health education on medication usage, effective in-hospital management of hyperglycemia, and increased access to high-quality care.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023432594.

Risk factors for diabetic ketoacidosis at first presentation of type 1 diabetes: an 8-year (2015-2022) audit at an Australian regional hospital

BACKGROUND

Risk factors for diabetic ketoacidosis (DKA) at first presentation of type 1 diabetes (T1DM) have been investigated in a small number of studies, but further studies are required to better define them. In particular, a family history of T1DM was shown to be protective, while the effect of pancreatic autoimmunity is uncertain.

AIMS

This retrospective study, performed at Townsville University Hospital, aimed to study whether the incidence of DKA at first presentation of T1DM was associated with (i) a family history of T1DM and (ii) the number and titre of pancreatic autoantibodies. This study was the first of its kind covering both adult and paediatric cohorts in regional Queensland, Australia.

METHODS

Patients diagnosed with T1DM between January 2015 and December 2022 were included. Medical and patient data were retrospectively collected and analysed using spss.

RESULTS

A total of 146 patients met the inclusion criteria. Seventy-eight (53.4%) patients presented with DKA, whereas 68 (46.6%) did not. Among patients with at least one relative with T1DM, 19 (36.5%) patients had DKA and 33 (63.5%) did not (odds ratio (OR): 0.35, confidence interval (CI): 0.17-0.72, P = 0.004). Among those with a first-degree relative with T1DM, four (18.2%) patients had DKA and 18 (81.8%) did not (OR: 0.16, CI: 0.05-0.49, P < 0.001). There was no significant difference in DKA incidence at diagnosis with status or titre of antibodies.

CONCLUSIONS

Family history was protective against DKA at first presentation of T1DM, whereas there was no relationship with the presence or titre of pancreatic autoantibodies.

Comparison between blood ketone and blood gas analysis indices in management of diabetic ketoacidosis

Objective

Blood ketone monitoring is commonly used in the management of diabetic ketoacidosis (DKA). However, bedside ketone meters have limited availability in hospitals. This study aimed to clarify the correlation between blood ketones and blood gas analysis (BGA) in the treatment of DKA and thereby identify parameters that can be used as surrogates for blood ketones.

Patients and Methods

This retrospective observational study included patients with DKA admitted to the JA Toride General Medical Center between November 2021 and March 2024. Multiple regression analysis was performed using blood ketone levels as the objective variable and BGA indices as explanatory variables. Additionally, the study evaluated 1) the time course of ketone levels and BGA indices during the DKA treatment and 2) the correlation between ketone levels and the BGA indices.

Results

Sixteen patients were enrolled. Multiple regression analysis showed that the corrected anion gap (cAG), defined as the anion gap minus lactate concentration, was a significant predictor of blood ketones. Among pH, HCO3 -, and cAG, only cAG had significant regression coefficients (-0.061 [95% confidence interval (CI): -3.49 to 1.98], -0.233 [-0.156 to 0.0118], 0.636 [0.129 to 0.246], respectively; coefficient of determination: 0.765). The correlation coefficient between cAG and blood ketone levels was high (0.9694).

Conclusion

cAG levels strongly correlate with blood ketone concentrations and may serve as a surrogate marker for blood ketones in the management of DKA. Because measurements of the anion gap and lactate concentrations are inexpensive and widely available in most medical facilities, cAG is a promising indicator for DKA management.

Balanced Fluids Versus Normal Saline for Initial Fluid Resuscitation in Adults With Diabetic Ketoacidosis

Background: Normal saline (NS) has been the choice fluid for volume resuscitation in diabetic ketoacidosis (DKA) for decades. Large volume resuscitation with NS can lead to hyperchloremic metabolic acidosis and is associated with a higher incidence of major adverse kidney events compared to balanced fluids (BF). Objective: Compare safety and effectiveness of fluid resuscitation with BF vs NS in adult patients with DKA. Methods: Single-center retrospective cohort study evaluated patients who received NS or BF for DKA treatment between July 2020 and August 2021. Primary endpoint was time to DKA resolution. Secondary endpoints included time to anion gap ≤12, HCO3 ≥15 and ≥18 mmol/L, acute kidney injury, and hospital and intensive care unit length of stay. Results: 110 patients were included (NS 55% (n = 60), BF 45% (n = 50)). Time to DKA resolution was faster in patients who received BF vs NS (13 (10 - 19) hours vs 17 (11 - 25) hours, P = 0.02). Treatment with NS was associated with a longer time to resolution of DKA when adjusted for initial bicarbonate and AKI at admission. Conclusion: BF was associated with a shorter time to DKA resolution compared to NS.

Early parameter to detect the resolution of pediatric diabetic ketoacidosis

Objective

The present study aimed to analyze the incidence of hyperchloremia and compare the time to reach DKA resolution with different parameters.

Methods

A chart review of patients diagnosed with DKA and aged <18 years was conducted. DKA was defined as serum glucose ≧200 mg/dl, venous pH (vpH) <7.30, serum bicarbonate <15 mmol/L, and presence of ketonemia, or ketonuria. Electrolytes and blood gases were recorded at 6-h intervals after treatment initiation.

Results

Overall, 84 patients were admitted because of DKA. The initial biomedical parameters in the emergency department were as follows: median glucose, 497 mg/dl; vpH, 7.1; serum HCO3, 6.6 mmol/L; anion gap (AG), 24.7 mmol/L; and ketone, 5.7 mmol/L. After treatment, the incidence of hyperchloremia increased progressively from 15.4% at treatment initiation to 80% at 18 h. The median time to resolution defined by AG ≦12 mmol/L was 12 h, which was significantly faster than the recovery of vpH ≧7.3 (median time, 17 h) and HCO3 >15 mmol/L (median time, 18 h). Approximately 63 (75%) patients reached the endpoints of AG ≦12 mmol/L prior, 14 (16.6%) patients reached the endpoints of vpH ≧7.3 prior, 7 (8.4%) patients reached the endpoints of HCO3 >15 mmol/L prior.

Conclusions

Hyperchloremic metabolic acidosis (HMA) was a common entity in pediatric DKA following treatment. The median time of AG ≦ 12 mmol/L was approximately 12 h and was the parameter that can identify DKA resolution at a faster rate, i.e., approximately 5, and 6 h faster than the normalization of vpH and HCO3, respectively. Future studies were warranted to use AG ≦12 mmol/L as the endpoint of DKA treatment and check if the treatment course and incidence of HMA could be reduced.

Comparative Analysis of Diabetic Ketoacidosis in Adults With Type 1 and Type 2 Diabetes Mellitus: Insights From a Saudi Arabian Cohort

Background: Diabetic ketoacidosis (DKA) is a life-threatening complication commonly seen in Type 1 diabetes mellitus (T1DM) but also affects Type 2 diabetes mellitus (T2DM). Objectives: To compare the clinical presentation, biochemical parameters, and precipitating factors of DKA in adult patients with T1DM and T2DM. Methodology: This retrospective cohort study was conducted at King Salman Hospital, Riyadh, involving medical records of diabetic patients aged 14 years or older who attended the Diabetic Center from September 1, 2021, to August 1, 2022. Data collection included sociodemographic, clinical, biochemical, and management details using a standardized checklist. Results: The study included 285 patients with DKA, aged 14-70 years (mean: 23.1 ± 11.5 years), with 52.5% being male. The most common symptoms were nausea (91.1%), abdominal pain (86.1%), vomiting (83.6%), polyuria/polydipsia (74.1%), and shortness of breath (72.4%). Vomiting and abdominal pain were more frequent in T1DM (85.9% and 88.3%) compared to T2DM (65.6% and 68.8%), p=0.004 and 0.003, respectively, while dizziness was more common in T2DM (56.3% vs. 33.2%), p=0.011. Uric acid and creatinine levels were significantly higher in T2DM, whereas hemoglobin and hematocrit were elevated in T1DM. Poor compliance was the most common precipitating factor (70.2%), followed by upper respiratory tract infection (21.1%) and inadequate treatment (15.6%). Conclusion: This study highlights key differences in DKA presentation between T1DM and T2DM. While symptoms such as nausea and abdominal pain were common in both types, vomiting was more frequent in T1DM and dizziness in T2DM. Biochemical markers such as uric acid and creatinine were elevated in T2DM, while hemoglobin and hematocrit were higher in T1DM. Poor compliance was a more common precipitating factor in T1DM, whereas inadequate treatment prevailed in T2DM. Tailored management approaches for each diabetes type may improve DKA outcomes.

In vivo Raman spectroscopy for non-invasive transcutaneous glucose monitoring on animal models and human subjects

Non-invasive glucose monitoring represents a significant advancement in diabetes management and treatment as non-painful alternatives than finger-sticks tests. After developing an integrated Raman spectral system with a 785 nm laser, this study systematically explores the application of in vivo Raman spectroscopy for quantitative, noninvasive glucose monitoring. In addition to observing characteristic glucose spectral information from a mouse model, a strong spectral correlation was also recognized with the blood glucose concentration. The glucose fingerprint information detected from the nailfolds of 30 human volunteers exhibited concentration dependent changes, especially when the intraspectrum intensity ratio was calculated between 1125 cm-1 and 1445 cm-1 to monitor normalized differences in the glucose Raman band. Furthermore, by accounting for all intersubject variations observed in the acquired spectral features, a particle swarm optimization-backpropagation artificial neural network (PSO-BP-ANN) model was proposed for linking measured Raman information with actual glucose concentrations quantitatively. Following model training and testing, the prediction accuracy of the PSO-BP-ANN model was evaluated using 12 spectra acquired from an additional three volunteers. Statistical evaluations indicated that the proposed methodology may have a good application potential for in vivo transcutaneous spectral glucose monitoring.

The Effect of Atrial Fibrillation on Mortality Outcomes in Patients Admitted With Diabetic Ketoacidosis

This study aims to identify the effect of atrial fibrillation on mortality in patients admitted with DKA. We used the National Inpatient Sample Database for the year 2018 and 2019 to identify patients hospitalized with DKA. Association of atrial fibrillation was confirmed using the International Classification of Disease, Tenth Edition (ICD 10 CM). We performed a retrospective analysis on this database using STATA (Stata Corp, College Station, TX). The primary outcome was mortality in DKA. Length of stay (LOS) and total hospitalization charge were the secondary outcomes. There was a total of 447,570 DKA patients out of which 12,770 had associated atrial fibrillation in the year 2018-2019. The mean age of patients with DKA and AFIB was 62 years. Approximately 46% of patients were female in DKA with AFIB group. The multivariate logistic analysis showed increased mortality in patients with DKA and AFIB (OR = 1.4, p = 0.048). Predictors of increased mortality were older age and in metropolitan areas (OR = 1.0, p < 0.001 and OR = 1.4, p = 0.031 respectively). LOS was lower in patients with DKA and AFIB compared to DKA alone (3.1 day and 5.2 days respectively, OR = 0.82, p < 0.001). Total hospitalization charge was higher for patient in DKA with AFIB (USD 53,576 and USD 32,533 respectively, coefficient = 10,513, p < 0.001). Patients hospitalized with DKA and AFIB had higher mortality compared to patients without AFIB, while they showed lower LOS but increased hospitalization cost. Further research in this direction would be helpful to better understand this association.

The effect of oral nutrition on diabetic ketoacidosis resolution time: Retrospective Cohort study

PURPOSE

Diabetic ketoacidosis (DKA) is a serious disease that requires urgent and aggressive intervention. Although the medical treatments and protocols are well established, the role of oral nutrition during DKA treatment remains unclear. We aimed to evaluate the effect of oral nutritional status on the resolution rate of DKA.

MATERIAL AND METHODS

This retrospective cohort study is a single-centre study consisting of patients who were admitted with a diagnosis of DKA and were followed up in the ward. Patients were divided into two groups based on their oral nutrition status. The first group consisted of patients who received open oral nutrition during DKA treatment. The second group consisted of patients whose oral feeding was stopped until DKA resolved. Factors such as diabetes-related characteristics, DKA resolution time, and length of hospital stay were compared between the groups. The Chi-square test and Mann-Whitney U test were used for comparisons between groups.

RESULTS

Of the 51 DKA patients evaluated, 29 were in the open oral feeding group, while there were 22 patients in the oral feeding stopped group. The recovery time for DKA was 9.9 ± 9.1 h in the oral nutrition group and 20.2 ± 13.7 h in the oral nutrition stopped group (p < 0.001). The mean length of hospital stay was 5.9 ± 3.3 days in the oral nutrition group and 7.4 ± 5.9 days in the oral nutrition stopped group (p = 0.346). The mean anion gap normalization time was 12.5 ± 8.6 h in the open oral feeding group and, 22.6 ± 14 h in the oral feeding stopped group (p < 0.001).

CONCLUSION

Oral nutrition until DKA resolves allows the patient to recover more quickly and have a shorter hospital stay. These findings suggest a relationship between oral nutrition and faster DKA recovery.

Diabetic foot ulcer care integrating Salmon White's model: the critical role of community nurses

Patients with diabetic foot ulcers (DFUs) often face significant challenges in receiving optimal care in the community. This condition can lead to serious complications if not addressed, including infection, delayed healing, amputation, decreased quality of life, financial burdens and mobility impairments. Community nurses are uniquely positioned to support DFU management, as they serve as the first point of contact for individuals managing this condition. They offer essential education on foot care and emphasise the importance of early intervention. In this context, using Salmon White's model can empower nurses to prevent these complexities effectively. However, there is a lack of nursing review studies in the literature that integrate Salmon White's model with a focus on community care for DFUs. This article, based on three case studies, proposes a paradigm of DFU care that community nurses can adopt to provide comprehensive support within the community.

A Case of Diabetic Ketoacidosis With Persistent Alkalosis

Diabetic ketoacidosis (DKA) is an emergent complication of diabetes. Patients with DKA typically have an arterial pH of 7.30 or lower, caused by the overproduction of β-hydroxybutyric and acetoacetic acids. We present a case of a 24-year-old male with a history of uncontrolled type 1 diabetes mellitus, noncompliance, and gastroparesis who presented to an emergency department with nausea, nonbilious vomiting, and abdominal pain. The physical exam was remarkable for dry mucous membranes, tachycardia, and mild diffuse abdominal tenderness. Initial bloodwork indicated hyperglycemia, increased levels of beta-hydroxybutyric acid, and an elevated anion gap; however, the arterial pH was alkalotic. This led to the suspicion of a combined acid-base disturbance, where profuse vomiting resulted in alkalosis, masking the expected acidosis. The patient was started on intravenous fluids and an insulin drip and was subsequently admitted to the medical intensive care unit. He left the hospital against medical advice two days later. This case is notable because the patient met all the criteria for DKA yet exhibited an alkalotic pH. It highlights the necessity of using the entire clinical picture and not solely relying on laboratory values when diagnosing and treating disease.

Clinical Profile of Acute Kidney Injury in Type 2 Diabetes Mellitus Adult Patients Presenting With Diabetic Ketoacidosis: A Cross-Sectional Study

OBJECTIVE

 The purpose of this cross-sectional study was to identify the characteristics of acute kidney injury (AKI) in adult patients with type 2 diabetes mellitus (T2DM) who were admitted with diabetic ketoacidosis (DKA).

METHODOLOGY

 One hundred patients were selected based on the inclusion and exclusion criteria. Kidney function was assessed using kidney estimated glomerular filtration rate (KeGFR) calculations based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Data collection included clinical, biological, and demographic information. Univariate and multivariate logistic regression analyses were performed, with a p-value of less than 0.05 considered statistically significant. The study also examined risk factors, intensive care unit (ICU) treatments, and clinical outcomes.

RESULTS

AKI was significantly associated with ICU length of stay (p = 0.002), and all patients with prolonged ICU admission developed this condition. A higher incidence of AKI was observed in patients requiring mechanical ventilation, renal replacement therapy, or inotropic support. Among the 100 patients included in the study, 94 achieved clinical recovery, including 76 who had AKI, while six patients did not survive.

CONCLUSION

AKI is a common complication of DKA in adults with T2DM, particularly in hot climate regions. Most cases were detected within the first 24 hours, classified as stage 1 severity, and were pre-renal. Early detection plays a crucial role in preventing complications and improving patient recovery. KeGFR calculations proved an effective tool for monitoring kidney function changes in these patients.

Beyond Glucose Levels: Redefining Diabetic Ketoacidosis-A Case of Hypoglycemic Diabetic Ketoacidosis

Background/Objective

Diabetic ketoacidosis (DKA) is a life-threatening condition typically diagnosed by the presence of hyperglycemia, acidemia, and ketonemia. A subset of patients may develop ketoacidosis without the traditionally increased glucose levels in a condition known as euglycemic DKA. This article describes an atypical presentation of DKA with concomitant hypoglycemia in a condition termed hypoglycemic DKA.

Case Report

A 74-year-old woman with a history of hypertension, type 2 diabetes mellitus (treated with empagliflozin), and hypothyroidism, presented from an outlying hospital due to concern for acute gallstone pancreatitis and choledocholithiasis. On arrival, laboratory evaluation revealed an anion gap of 16 mEq/L (reference range, 6-12 mEq/L), bicarbonate level of 11 mEq/L (reference range, 21-31 mEq/L), serum glucose level of 57 mg/dL (reference range, 70-105 mg/dL), beta-hydroxybutyrate level of 1.7 mmol/L (reference range, <0.6 mmol/L), and urinalysis demonstrating a ketone level of >80 mg/dL (reference range, <3.49 mg/dL). The patient was treated according to the institution DKA protocol, with resolution of her DKA.

Discussion

The case presented highlights a manifestation of DKA characterized by a concurrent state of hypoglycemia in a patient treated with a sodium-glucose cotransporter 2 inhibitor, an atypical and likely underreported phenomenon.

Conclusion

Clinicians should maintain a high level of suspicion for DKA in patients with metabolic acidosis and ketosis, irrespective of their glucose levels, in particular in those treated with sodium-glucose cotransporter 2 inhibitors. Additionally, redefining these cases as drug-induced ketoacidosis may assist in preventing delayed diagnosis and management.

Pathophysiology, diagnosis, and management of immune checkpoint inhibitor-induced diabetes mellitus

Immune Checkpoint Inhibitors (ICIs) have revolutionized cancer treatment, offering hope for patients with various malignancies. However, along with their remarkable anticancer effects, ICIs can also trigger immune-related adverse events (irAEs). One such noteworthy complication is the development of Diabetes Mellitus (DM), which particularly resembles Type 1 Diabetes Mellitus (T1DM). The aim of this review is to provide insights into the epidemiology, pathophysiology, diagnostic issues, and treatment considerations of ICI-induced DM (ICI-DM), emphasizing the importance of early recognition and management to mitigate adverse outcomes. Although still rare, the incidence has increased with the widespread use of ICIs, especially PD-1/PD-L1 blockers (from 0.2% to 1.9%). Factors affecting the development of ICI-DM, such as specific ICIs, patient demographics, and genetic predispositions, are discussed. The complex interplay between immune dysregulation and pancreatic β-cell destruction contributes to diagnostic challenges, with presentations varying from asymptomatic hyperglycemia to diabetic ketoacidosis (DKA). Management strategies prioritize meticulous glycemic and electrolyte regulation along with tailored intravenous insulin therapy in cases of DKA. DM remission is rare, therefore treatment with both long-acting insulin at bedtime and short-acting insulin before meals is needed in longterm. Total daily insulin requirements can be estimated at 0.3-0.4 units/kg/day for most patients as a starting dose.

Buffered salt solution versus 0.9% sodium chloride as fluid therapy for patients presenting with moderate to severe diabetic ketoacidosis: Study protocol for a Phase-3 cluster-crossover, blinded, randomised, controlled trial

Background

The optimal choice of fluid therapy for patients with diabetic ketoacidosis (DKA) is uncertain, though preliminary data suggest that buffered crystalloid solutions (Plasma-Lyte® 148) may offer some advantages over 0.9% saline.

Objective

To describe the study protocol for the 'Balanced Electrolyte Solution versus Saline Trial for Diabetic Ketoacidosis' (BEST-DKA) trial.

Design setting and participants

BEST-DKA is a Phase 3 cluster-crossover, blinded, pragmatic, randomised, controlled trial comparing the effects of saline or buffered crystalloid solution in patients with moderate to severe DKA treated in the emergency department and/or intensive care unit at twenty hospitals in Australia. Each hospital will be randomised to use either saline or buffered crystalloid solution for a period of 12 months before crossing over to the alternate fluid for the next 12 months. The blinded study fluid will be used for all resuscitation and maintenance purposes for included patients.

Main outcome measures

This cluster-randomised, crossover randomised controlled trial (RCT) has been designed with the aim of enrolling a minimum of 400 patients, which will provide >91.4% power to detect a 2-day increase in the primary outcome, days alive and out of hospital to day 28, chosen with consumer representation. Secondary outcomes include quality of life and fatigue scores at day 28, intensive care unit and hospital lengths of stay, acute kidney injury, and time to resolution of DKA. All analyses will be conducted on an intention-to-treat basis. A prespecified statistical analysis plan will be developed prior to interim analysis.

Results and conclusion

The BEST-DKA trial commenced enrolment in March 2024 and should generate results that will determine whether treatment with Plasma-Lyte® 148, compared with saline, results in increased days alive, and out of hospital to day 28 for patients with moderate or severe DKA.

Diabetes Management in the Critical Care Setting: Insulin Infusions

Hyperglycemia is common in critically ill patients. Due to the complex medical issues of critically ill patients, continuous insulin infusions are often used to treat hyperglycemia in the ICU. This article discusses the benefits and risks of continuous insulin infusions, components of insulin infusion protocols, nursing management while administering insulin infusions, and proper transition off an insulin infusion.

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

BACKGROUND

Diabetic ketoacidosis (DKA) is often treated with intravenous regular insulin infusion (IVRII). Subcutaneous fast-acting insulin analogues (FAIAs); either alone or combined with subcutaneous long-acting insulin (LAI); might be useful to treat DKA. Our meta-analysis updated on their benefits and safety in DKA.

METHODS

We searched major electronic databases for randomised trials on subcutaneous FAIAs ± subcutaneous LAI vs IVRII in DKA. Primary outcomes were all-cause in-hospital mortality, time to resolution of DKA and hyperglycemia, in-hospital DKA recurrence and hospital readmission for DKA post-discharge. Secondary outcomes included resource utilisation and patient satisfaction. Safety outcomes were adverse events. Reviewers assessed risk of bias and quality of evidence using GRADE. We performed a priori subgroup and trial sequential analyses on primary outcomes.

RESULTS

Seven trials enrolled 351 mainly adult patients (255/351) with mild to moderate DKA. No trials studied subcutaneous FAIA and subcutaneous LAI. Their risk of bias was high or unclear in several domains. No all-cause in-hospital mortality and DKA recurrence were reported. No trial investigated hospital readmission for DKA post-discharge. There was no difference in mean time to resolution of DKA (mean difference = -0.70, 95% CI -2.18 to 0.79 h, p = 0.36) or hyperglycemia [blood glucose < 250 mg/dL (13.9 mmol/L)] (mean difference = -0.17, 95% CI -1.10 to 0.76 h, p = 0.72) between subcutaneous FAIA and IVRII groups. There were largely no subgroup effects. Both groups had similar secondary outcomes. Hypoglycemia was the most common adverse event. Quality of evidence was low to very-low for all outcomes. The only possible trial sequential analysis for time to resolution of DKA was inconclusive.

CONCLUSIONS

There was low- to very-low quality evidence that subcutaneous FAIA did not affect patient-centered outcomes in mainly adult patients with mild to moderate DKA compared to IVRII.

Predictive Factors for Diagnosing Diabetic Ketoacidosis or Simple Hyperglycemia in Adults With High Blood Glucose: The "1-DKA Alert" Study

Background

Hyperglycemia is commonly encountered in the Emergency Departments, necessitating the differential diagnosis between diabetic ketoacidosis (DKA) and simple hyperglycemia, as the treatment and prognosis differ significantly. In clinical practice, it is essential to investigate DKA in all patients; however, the final diagnosis of actual DKA is found in only 1-5% of these cases, resulting in unnecessary costs. This study aimed to develop an application for predicting the probability of DKA in patients with capillary blood glucose levels exceeding 250 mg/dL in the Emergency Department.

Methods

This study was conducted as diagnostic prediction research, employing a retrospective observational delayed-type cross-sectional design. Data were collected from patients with capillary blood glucose levels exceeding 250 mg/dL between January and April 2023. The predictive variables were available at the time of prediction. Analysis was performed using multivariable risk ratio regression analysis, with results reported as multivariable risk ratios. The area under the receiver operating characteristic (AuROC) curve was calculated. Internal validation was performed using bootstrapping and calibration plots. An application named "1-DKA Alert" was developed to predict the probability of DKA for use in real-world clinical settings.

Results

The study included 274 adult patients, of whom 52.9% were female, with an average age of 59 years. Predictive factors for DKA included initial capillary blood glucose, type of diabetes mellitus, insulin usage, poor compliance, respiratory rate, and suspected infection. These variables were readily available in clinical practice and yielded an AuROC of 0.8777 (95% confidence interval (CI): 0.8294 - 0.9259). Bootstrapping internal validation demonstrated an AuROC of 0.8770 and a shrinkage factor of 0.991.

Conclusions

The "1-DKA Alert" demonstrates excellent discriminative ability, and the model is valid, suggesting its potential for use in clinical practice. However, further studies for external validation are necessary.

Aruncus Dioicus Var. Kamtschaticus Extract Prevents Ocular Endoplasmic Reticulum Stress, Inflammation, and Oxidative Stress In Vitro

The aim of this study was to determine the anti-inflammatory and anti-endoplasmic reticulum (ER) stress effects of Aruncus dioicus var. kamtschaticus (ADK) extract on ARPE-19 cells. Pretreatment with ADK effectively mitigated thapsigargin (Tg)-induced increases in vascular endothelial growth factor protein secretion and intracellular calcium levels. Furthermore, pretreatment with ADK suppressed ocular ER stress-related protein expression in a dose-dependent manner, inhibited the loss of tight junctions, and suppressed interleukin-6 gene expression. Moreover, ADK pretreatment significantly prevented lipopolysaccharide-inducible proinflammatory cytokine gene expression at the transcription level and the phosphorylation of proteins involved in the mitogen-activated protein kinase-nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) axis at the posttranslational level. Additionally, ADK extract enhanced antioxidant activity, as evidenced by increased heme oxygenase-1 protein expression and increased 2,2-diphenyl-1-picrylhydrazyl radical scavenging and ferric-reducing antioxidant power. In conclusion, ADK extract effectively protected ARPE-19 cells from ocular ER stress, inflammation, and oxidative stress, demonstrating its potential as a nutraceutical intervention for ocular diseases.

Review of Subcutaneous Insulin Regimens in the Management of Diabetic Ketoacidosis in Adults and Pediatrics

OBJECTIVE

Summarize the studies evaluating the use of subcutaneous (SQ) insulin in the management of diabetic ketoacidosis (DKA) in adults and pediatrics.

DATA SOURCES

A PubMed literature search was conducted for articles published between 2000 and the end of May 2024 which contained the following terms in their title: (1) subcutaneous, glargine, or basal and (2) ketoa*.

STUDY SELECTION AND DATA EXTRACTION

Review articles, guidelines, meta-analysis, commentaries, studies not related to the acute management of DKA, studies evaluating continuous SQ insulin, animal studies, if the time to DKA resolution was not clearly defined, and studies where basal insulin was administered greater than 6 hours after the insulin infusion was started were excluded.

DATA SYNTHESIS

The electronic search identified 58 articles. Following the initial screening 38 articles were excluded and 3 were added after bibliography review. Of the 23 articles assessed for eligibility, 7 were excluded. Sixteen articles were included. Five studies compared SQ rapid/short-acting insulin and intravenous (IV) insulin infusions in adults, 4 compared SQ rapid/short-acting insulin and IV insulin infusions in pediatrics, 4 evaluated IV insulin infusions with or without SQ basal insulin in adults, and 3 evaluated IV insulin infusions with or without SQ basal insulin in pediatrics.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

In comparison with IV insulin infusions, rapid/short-acting SQ insulin regimens were associated with reduced ICU admission rates, hospital length of stay, and hospitalization costs. IV insulin infusion regimens that included a single SQ basal insulin dose upon therapy initiation were associated with reduced concurrent IV insulin infusion durations.

CONCLUSION

Studies reviewed suggest that SQ insulin regimens may be as effective and safe as IV insulin infusions in the management of DKA and are associated with the conservation of resources. Providers may refer to this review when establishing or modifying their DKA management protocols.

Poor glycemic control and its predictors among people living with diabetes in low- and middle-income countries: a systematic review and meta-analysis

INTRODUCTION

Variability in blood glucose remains a challenge in diabetic management. Therefore, this review aimed to estimate the overall poor glycemic control and identify its predictors among people living with diabetes in low- and middle-income countries (LMICs).

METHODS

The authors searched articles in PubMed, Embase, OVID, CINAHL Plus, Cochrane Library, PsychInfo, Google, and Google Scholar. The search results were exported to the Rayyan software to check their eligibility. The Newcastle-Ottawa scale was used to assess the study quality. Stata version 17 was used for analysis. A random effect model was computed. Heterogeneity was assessed by the Cochrane Q test and I-squared (I2). The funnel plot asymmetry test and/or Egger's regression test (p < 0.05) were used to detect the publication bias. Then it was treated by the trim and fill analysis. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the reference number CRD42023430175.

RESULTS

In total, forty-nine articles were used. Of which forty-five articles with 15,981 participants were used for pooled prevalence estimation. The pooled prevalence of poor glycemic control among people living with diabetes in LMICs was found to be 69.06% (95% CI: 65.66-72.46), I2 = 96.1%, p < 0.001). Alcohol intake (AOR = 2.07: 95% CI: 1.27-3.36), poor adherence to dietary recommendations (AOR = 3.16, 95% CI: 1.13-8.85), poor adherence to anti-diabetic medication (AOR = 2.85, 95% CI: 1.04 -7.85), diabetic complications (AOR = 1.37, 95% CI: 1.00-1.88), and co-morbid conditions (AOR = 1.98, 95% CI: 1.28-30.07) were found to be predictors of poor glycemic control.

CONCLUSIONS

The pooled prevalence of poor glycemic control was significantly high in LMICs. Drinking alcohol, poor adherence to dietary recommendations, poor adherence to anti-diabetic medication, diabetes complications, and co-morbid conditions were found to be the determinants of poor glycemic control among people living with diabetes. Tight glycemic control strategies have been implemented to achieve optimal blood glucose. Further research on the regional and contextual factors influencing glycemic control would be recommended.

DEKODE-A cloud-based performance feedback model improved DKA care across multiple hospitals in the UK

AIM

A current gap in Diabetes-related ketoacidosis (DKA) research is understanding the factors contributing to variations in care and outcomes between people admitted with DKA. We aimed to create a system to facilitate gathering data on DKA management across multiple centres and identify trends in complications and outcomes associated with DKA.

RESEARCH DESIGN AND METHODS

Between January 2020 and December 2022, we set up a cloud-based Quality improvement project (QIP) that provided regular feedback to 11 hospitals in the United Kingdom (UK).

RESULTS

Of the 1977 episodes, we observed an increase in adherence in fluid prescription in hospitals C, D, E, F and G (C- 23% vs. 75% p = <0.001; D- 27% vs. 60%, p = <0.001; E- 17 vs. 79% p = <0.001; F- 16% vs. 57%, p = <0.001; G- 36% vs. 75% p = <0.001). Notable improvements in adherence to glucose monitoring were observed in hospitals B, D, and G (B- 11 vs. 38% p = <0.001; D- 36% vs. 56%, p = 0.05; G- 22% vs. 67% p = <0.001). Although we didn't observe significant changes in complications and outcomes among participating hospitals from the start to the end of the reported period, notable fluctuations were evident across quarters. These variations were relayed to the respective hospitals, underscoring how feedback and interventions could influence the care provided. This initiative also marks the initial move towards establishing and improving data collection practices in acute diabetes.

CONCLUSIONS

We demonstrate a sustainable QIP that improves adherence to national guidelines in some indicators for DKA care and serves as an early warning system to identify adverse trends.

Diabetic ketoacidosis and hyperglycemic hyperosmolar state are associated with higher in-hospital mortality and morbidity in diabetes patients hospitalized with ST-elevation myocardial infarction, but not within 30 days of readmission

BACKGROUND

While the cardiovascular risk of hyperglycemia has been thoroughly elucidated in patients with type 2 diabetes (T2DM) hospitalized for myocardial infarction, the evidence surrounding acute severe hyperglycemia is less well-established. Our study aimed to explore the impact of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS), both severe hyperglycemic conditions, on cardiovascular outcomes in patients with T2D admitted for ST-elevation myocardial infarction (STEMI).

METHODS

We used the National Readmission Database (2016-2019) to extract patients with T2DM and STEMI at baseline. Subsequently, we selected cases of DKA and HHS. The primary endpoint was in-hospital mortality. Secondary endpoints included in-hospital acute renal failure, cardiogenic shock, and 30-day readmission and mortality.

RESULTS

The presence of DKA increased the adjusted odds of mortality and cardiogenic shock by almost 2-fold (adjusted Odds Ratios aOR = 2.30 [1.70-3.12], 2.055 [1.602-2.637], respectively) and renal failure by nearly 5-fold (aOR = 5.175 [4.090-6.546]). HHS was also associated with higher odds of mortality, acute renal failure, and cardiogenic shock. In 30 days, DKA and HHS increased the risk of readmission (aOR = 1.815 [1.449-2.75], 1.751 [1.376-2.228], respectively). There were no differences in the rates of cardiovascular disease, mortality, or other cardiovascular events between DKA and HHS patients. Within 30 days of readmission, DKA and HHS were associated with higher odds of readmission but not mortality. Cardiovascular disease was the most common etiology of readmission in all patients. The incidence of non-STEMI was the highest in DKA patients, and the incidence of STEMI was the highest in the HHS group.

CONCLUSION

The presence of diabetic ketoacidosis or hyperglycemic hyperosmolar state is associated with higher odds of mortality, renal failure, cardiogenic shock, and 30-day readmission in STEMI patients with type 2 diabetes, highlighting the need for enhanced clinical management and monitoring of patients experiencing acute hyperglycemia.

Continuous Glucose Monitoring in Hospitalized Adults With Diabetic Ketoacidosis: A Prospective Open-Label Pilot Study

BACKGROUND

Continuous glucose monitoring (CGM) devices are increasingly used in critical and non-critical care hospital units. The efficacy of CGM in assessing glucose control in adults with diabetic ketoacidosis (DKA) is unknown.

METHODS

This single-center pilot study compared glycemic control by real-time CGM (Dexcom G6), capillary point-of-care (POC), and basic metabolic panel (BMP) during intravenous (IV) insulin treatment and after the resolution of DKA. We compared the mean absolute relative difference (MARD), median absolute relative difference (ARD) glucose values, and Diabetes Technology Society (DTS) Error Grid analyses.

RESULTS

We recruited 52 patients (49 ± 19 years, admission glucose: 503 ± 239.4 mg/dL) with type 1 diabetes (n = 24) and type 2 diabetes (n = 28). Compared with POC testing, the MARD was 17.4% ± 13.2%, and the median ARD was 14.2% (interquartile range [IQR]: 6.4, 28) during the initial IV insulin period and 19.8% ± 18.7% and 14.3% (7, 26.2) after DKA resolution. The DTS Error Grid analysis showed that 100% of values during the IV insulin treatment and 95% after the DKA resolution were in zones A+B. Compared with BMP glucose values, the MARD and median ARD were 18.5% ± 19.1% and 12.2% (5.4, 23.8) during the IV insulin treatment and 22.5% ± 24.7% and 15.1% (6.6, 27.6) after DKA resolution.

CONCLUSION

This is the first report on the use of real-time CGM in adults with DKA. Our study indicates that CGM technology is a reliable tool for hospital use during acute insulin treatment and after the resolution of DKA. Future multicentre randomized studies are needed to determine the benefits of real-time CGM in facilitating diabetes care in hospitalized patients with hyperglycemic crises.

Assessment of Patient Satisfaction Among Patients Treated With Intravenous vs Subcutaneous Insulin for Diabetic Ketoacidosis

Objectives

We previously implemented the subcutaneous (SQ) insulin in diabetic ketoacidosis (DKA) (SQuID) protocol, demonstrating safe, effective treatment of low to moderate (LTM) severity DKA in a non-intensive care unit setting. SQuID replaces intravenous (IV) insulin with SQ injections and reduces glucose checks from hourly to every 2 hours. We are not aware of any data on patient satisfaction with treatment in DKA. Our objective was to compare satisfaction in patients treated with IV insulin to that in patients treated with the SQ protocol.

Methods

We conducted a cross-sectional study in an urban academic hospital (March 2023 to March 2024) of emergency department patients treated for LTM DKA with SQ or IV insulin. Patients were contacted by phone in the hospital after the resolution of DKA. We used the validated 21-item Diabetic Treatment Satisfaction Questionnaire-Inpatient tool (DTSQ-IP) using 7-tier Likert-style options (0 = negative; 6 = positive) to assess patient satisfaction with treatment. We computed the DTSQ-IP composite treatment satisfaction score (using 15 of the 21 items), assessing differences between groups.

Results

Of the 60 patients contacted, 52 (87%) completed the questionnaire. Median DTSQ-IP satisfaction scores for SQuID and IV insulin patients were 86.0 (IQR, 79.0, 88.0) and 81.0 (IQR, 77.0, 88.0), respectively. We found no difference in satisfaction between groups (difference 5.0; 95% CI, -3.0, 10.0).

Conclusion

In this single-center study, patient satisfaction with DKA care was high, with no differences observed between patients treated with SQ vs IV insulin protocols. This is the first study we are aware of on patient satisfaction with treatment in DKA or treatment with SQ insulin. Though the sample size is small, these findings suggest that patient satisfaction should not represent a barrier to the implementation of SQ protocols for LTM severity DKA.

Effect of exercise on plasma insulin levels in individuals with type 1 diabetes: A systematic review and meta-analysis

AIMS

Current evidence of the impact of acute exercise on insulin levels in individuals with type 1 diabetes remains controversial. Therefore, we conducted a systematic review and meta-analysis to explore exercise-induced changes in insulin levels.

MATERIALS AND METHODS

We conducted a systematic review (until 05 November 2023) and meta-analysis exploring the effect of exercise on insulin concentration in individuals with type 1 diabetes. We included randomised cross-over studies for rapid-acting insulin and pre- and post-studies for long-acting insulin in individuals with type 1 diabetes performing any type of acute exercise and had a control condition. The exercise-induced change in insulin levels was the outcome of interest. When possible, the mean differences (MDs) in insulin levels were pooled using the DerSimonian and Laird random effect method. Risk of bias was assessed for each included study.

RESULTS

Seventeen trials, encompassing 186 participants with type 1 diabetes, were included in the systematic review. Twelve out of 17 studies included participants on rapid-acting insulin regimens and used a cross-over design, whereas five out of 17 single-arm studies included participants on (ultra)long-acting insulin. Seven out of 12 studies on rapid-acting insulins and all the single-arm studies were at high risk of bias. Results suggest a statistically significant, small-to-moderate increase of rapid-acting insulin after 30 min of exercise (MD of 18.44 [95% CI 0.02; 36.86; I2 0%] pmol/L); meanwhile, findings on (ultra)long-acting insulin were inconclusive.

CONCLUSIONS

A small-to-moderate increase of insulin levels in studies including rapid-acting insulin was found after a bout of physical exercise in individuals with type 1 diabetes. However, current gaps in high-quality evidence challenge our understanding of insulin kinetics around exercise.

Analysis of the 2-Bag Method for the Management of Diabetic Ketoacidosis: A Retrospective before and after Study

Purpose: This study aims to assess the efficacy and safety of a two-bag method compared with a one-bag method for the treatment of diabetic ketoacidosis (DKA). We hypothesize that a two-bag method will decrease the incidence of hypoglycemia, when compared with a one-bag method. Methods: A retrospective chart review was conducted on patients treated for DKA at a Trinity Health institution between 2020 and 2022. A total of 1084 adult patients were included. Patients treated with the one-bag protocol were included in the pre-group, while those treated with the two-bag protocol were included in the post-group. The primary outcome was incidence of hypoglycemia (blood glucose <70 mg/dL). Secondary outcomes included time to anion gap closure, insulin infusion duration, time to HCO3 correction, and incidence of hypokalemia. Patients were excluded if they were pregnant or diagnosed with Hyperosmolar Hyperglycemic State (HHS), euglycemic DKA, or ketosis from other causes. Results: The incidence of hypoglycemia was 38% in the pre-group and 15.83% in the post-group (P < .001). Patients in the pre-group were on an insulin infusion longer than the post-group (28.37 hours vs 22.17 hours, P < .001). Patients in the pre-group had a slower time to anion gap closure (8.99 hours vs 8.52 hours, P = .021) and had a slower time to HCO3 correction (10.88 hours vs 10.69 hours, P = .004). Between-group incidence of hypokalemia was similar (66.39% vs 60%, P = .079). Conclusions: The two-bag method for the treatment of DKA resulted in improved safety and efficacy outcomes, compared with the one-bag method.

Pathophysiology, symptoms, outcomes, and evaluation of hyponatremia: comprehension and best clinical practice

This review article series on water and electrolyte disorders is based on the 'Electrolyte Winter Seminar' held annually for young nephrologists in Japan. The seminar includes lively discussions based on cases, which are also partly included in this series as self-assessment questions. The first article in this series focuses on pathophysiology, symptoms, outcomes, and evaluation of hyponatremia, a common water and electrolyte disorder in clinical practice. Diagnosing the root cause(s) of hyponatremia can be challenging due to various etiologies and co-morbidities that affect water and electrolyte homeostasis, which can result in inappropriate management and worse outcomes in acute and chronic hyponatremia. This review provides an overview of pathophysiology, symptoms, outcomes, and evaluation of hyponatremia for better comprehension and improved clinical practice.

Altered association between cortisol and adrenocorticotropic hormone levels in the early stage of type 2 diabetic ketoacidosis

Objectives

In the early stages of various critical infections and diseases, altered association of cortisol and adrenocorticotropic hormone (ACTH) levels occurs, with cortisol levels increasing and ACTH levels remaining normal or decreasing. This study aimed to explore the relationship between ACTH and cortisol levels in patients with diabetic ketoacidosis (DKA) and the influence of the severity of DKA.

Methods

A total of 106 type 2 diabetes patients with DKA admitted to the Endocrinology Department of Yantai Yuhuangding Hospital from February 2018 to May 2023 were divided into groups without (n=54) and with bacterial infection (n=52). Twenty type 2 diabetes patients without infection or DKA admitted during the same period were included as the control group. Cortisol and ACTH levels were measured on the first day of admission and the day after DKA correction for patients with DKA and on the first day of admission and the day before discharge for the control group.

Results

Compared with the control group, the DKA groups both with and without infection had significantly higher cortisol levels (P<0.05) and significantly lower ACTH levels (P<0.01) at admission. DKA patients with infection had significantly higher cortisol levels at admission than those without infection (734.51 ± 348.69 nmol/L vs 508.79 ± 268.72 nmol/L, P<0.01), while ACTH levels did not differ significantly between the two groups (P>0.05). After correction of DKA, no differences in cortisol or ACTH levels were observed among the three groups. Compared with levels at admission, DKA patients both with and without infection had lower cortisol levels and higher ACTH levels after DKA correction (all P<0.001). Multiple stepwise regression analysis showed that for all DKA patients and for subgroups with and without infection, the cortisol level at admission was independently positively correlated with the ACTH level and negatively correlated with the bicarbonate level (both P<0.01).

Conclusions

In the early stage of DKA, a phenomenon of altered association between cortisol-ACTH occurs and is especially prominent in DKA patients with infection. This altered association between cortisol-ACTH disappears after DKA correction, and the severity of DKA is an independent influencing factor on the cortisol level in early-stage DKA.

Burden of diabetic ketoacidosis and its predictors among diabetic patients in Ethiopia: Systematic review and meta-analysis

BACKGROUND

Multiple studies across Ethiopia have investigated the occurrence of DKA, showing significant variations and conflicting findings. This systematic review and meta-analysis seek to consolidate the overall prevalence of diabetic ketoacidosis and its associated factors in the Ethiopian context.

METHODS

The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines. Data was collected from PubMed/MEDLINE, Science direct, Google Scholar, and gray literature sources. Microsoft Excel was used for data extraction and summary, while the analysis was performed with R software version 4.3.2. The overall pooled prevalence of diabetic ketoacidosis and its components was estimated using a random effects model. Publication bias was assessed both graphically, using funnel plots, and statistically, with tests such as Egger's regression test. Subgroup analysis were carried out to minimize random variations in the estimates from the primary studies.

RESULT

The pooled estimated prevalence of diabetic ketoacidosis among diabetic patients in Ethiopia was 46% (95% CI; 36, 57; I2 = 100%, P≤0.001). Medication discontinuations (AOR = 1.30, 95 CI 1.20, 1.64), presence of comorbidity (AOR = 1.53, 95 CI 1.10, 2.20) and presence of infection (AOR = 1.62, 95 CI 1.31, 1.98) had an association with diabetic ketoacidosis among diabetic patients.

CONCLUSIONS

Medication discontinuations, comorbidity, and infection are individual contributors to diabetic ketoacidosis in diabetic patients. Implementing initiatives to enhance medication adherence and establish comprehensive diabetes management programs covering glycemic control, comorbidities, and infection management can effectively address these factors.

Severe Diabetic Ketoacidosis in Children with Type 1 Diabetes: Ongoing Challenges in Care

Diabetic ketoacidosis is the most common acute complication in children and adolescents with type 1 diabetes, and contributes significantly to morbidity, mortality, and healthcare burden. This review aims to explore the multifaceted aspects of severe diabetic ketoacidosis in pediatric age, including its epidemiology, pathogenesis, risk factors, complications and emphasizing advances in prevention strategies. Incidence rates vary due to influences from geographic, socioeconomic, cultural and demographic factors. Pathogenesis is linked to insulin deficiency and an excess of counter-regulatory hormones, which disrupt glucose, protein, and lipid metabolism, causing hyperglycemia, ketosis, acidosis, dehydration, and electrolyte imbalances. According to the International Society for Pediatric and Adolescent Diabetes guidelines, severe diabetic ketoacidosis is characterized by a pH < 7.1 or bicarbonate < 5 mmol/L. This condition can lead to a wide range of life-threatening complications, including cerebral edema that represents the leading cause of death. Several prevention strategies, including awareness campaigns, early diagnosis of diabetes, regular monitoring and management, effective insulin therapy, education, access to healthcare and technological assistance, may contribute to reduce the risk of severe diabetic ketoacidosis episodes in children and adolescents.

Predictors of 7-day mortality in critically ill patients with hyperglycemic crisis : A single center retrospective analysis

AIM/HYPOTHESIS

The main aim of the study was to identify point of care available laboratory and clinical predictors of 7‑day mortality in critically ill patients with a hyperglycemic crisis.

METHODS

A retrospective study of 990 patients with the first hospitalization due to hyperglycemia was performed. Patients were classified as having diabetic ketoacidosis (DKA) or being in a hyperosmolar hyperglycemic state (HHS) according to the recommendations of the American Diabetes Association (ADA). Patients not fulfilling the ADA criteria for DKA or HHS were summarized in a third group (unclassifiable hyperglycemia, UCH). The primary outcome was 7‑day mortality, potentially relevant factors were analyzed as secondary outcomes.

RESULTS

Overall, the 7‑day mortality was 7.5%, with no significant differences between DKA (7.8%), HHS (14.5%) and UCH (6.1%). Blood lactate levels were significantly higher in nonsurvivors than survivors in all three groups (mean level of 6.3 mmol/l vs. 3.4 mmol/l in DKA, 5.3 mmol/l vs. 3.1 mmol/l in HHS, 5 mmol/l vs. 2.5 mmol/l in UCH). Measured and calculated osmolality were significantly higher in nonsurvivors in the DKA group (measured osmolality 359 mosmol/kg vs. 338 mosmol/kg, calculated osmolality 315 mosmol/kg vs. 305 mosmol/kg) and patients with UCH (354 mosmol/kg vs. 325 mosmol/kg; 315 mosmol/kg vs. 298 mosmol/kg) but not in patients with HHS. Survival analysis for the DKA group showed no significant differences in 7‑day mortality when patients were compared by the ADA criteria of severity (severe, moderate, or mild). Patients with elevated calculated osmolality (> 320 mosmol/kg) and lactate (> 4 mmol/l) had the lowest 7‑day survival rate (66.7%).

CONCLUSION/INTERPRETATION

Our data showed that elevated lactate levels were associated with higher mortality in all types of hyperglycemic crises.

A Case of Euglycemic Diabetic Ketoacidosis in a Patient with Diabetic Foot Syndrome

Euglycemic Diabetic ketoacidosis (E-DKA) is a life-threatening emergency characterized by ketonemia and metabolic acidosis in presence of relatively normal glycemic values. In recent years it has been associated with some predisposing conditions including sodium-glucose transporter 2 inhibitors (SGLT2-i) therapy, widely used in high-risk cardiovascular patients. We report the case of a 78-year-old diabetic woman treated with dapagliflozin, affected by critical limb threatening ischemia and septic osteoarthritis of interphalangeal joint of first right toe. At admission blood exams allowed diagnosis of E-DKA associated to acute kidney failure. The occurrence of the condition was probably due to foot infection acting on a trigger on a SGLT2-i predisposition. We treated the patient according to guidelines' indications achieving the resolution of the metabolic derangement. After the control of acute condition and return of metabolic parameters within the normal range, the patient underwent revascularization procedure and surgical debridement eventually obtaining complete healing of foot lesion.

The effect of renal function on the clinical outcomes and management of patients hospitalized with hyperglycemic crises

Background

The global prevalence of diabetes has been rising rapidly in recent years, leading to an increase in patients experiencing hyperglycemic crises like diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Patients with impaired renal function experience a delay in insulin clearance, complicating the adjustment of insulin dosing and elevating hypoglycemia risk. Accordingly, this study aims to evaluate the impact of renal function on the safety and efficacy of insulin use in patients with isolated DKA or combined DKA/HHS.

Methods

A retrospective observational study was conducted at King Abdulaziz Medical City, Saudi Arabia, from January 2016 to December 2021. Eligible patients were ≥18 years, had a confirmed diagnosis of isolated DKA or combined DKA/HHS, presented with an anion gap (AG) of ≥ 16 mmol/L, and received insulin either via continuous infusion or as bolus doses. Patients were categorized into normal kidney function and patients with chronic kidney disease (CKD). The primary outcome was to determine the difference in time to close the AG between the two groups. Statistical analyses were performed using SAS® software.

Results

Out of 319 screened patients, 183 patients met the inclusion criteria. The patients were divided into normal kidney function (43.2%) and CKD (56.8%) groups. The average eGFR for patients with normal kidney function was 93.7 ± 32.5 mL/min/1.73m2 compared to 33.4 ± 14.3 mL/min/1.73m2 for patients with CKD. The time to close AG was similar between patients in the normal kidney function and CKD groups (22.6 ± 16.0 hours vs. 24.5 ± 17.5 hours, p=0.4475). However, the patients' length of stay in hospital (3.4 ± 2.5 days vs. 5.2 ± 4.0 days; p=0.0004) and ICU (2.5 ± 1.8 days vs. 4.0 ± 2.8 days; p=0.0453) were both significantly longer for patients with CKD. Hypoglycemic events were low in our study with only four documented cases among patients with CKD.

Conclusion

This study provides insights into DKA management and outcomes in patients with normal and impaired renal function. The time required to close AG was comparable between the two groups. Larger, multi-center studies are needed to validate these findings and explore additional factors that may impact the management of DKA in patients with CKD.

Life-threatening dapagliflozin-associated euglycaemic diabetic ketoacidosis in a postoperative patient

Euglyceamic diabetic ketoacidosis (EuDKA) is an uncommon but serious diabetes mellitus complication associated with risk factors such as fasting, surgery, pregnancy and, more recently, the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). This case is of a woman with type 2 diabetes and hypertension in her 50s who underwent an incarcerated umbilical hernia repair and abdominoplasty. Two days after discharge, she was readmitted with nausea, vomiting, loss of appetite, low-grade fever and breathing difficulty. Preoperatively, her diabetes management included an SGLT2i. She was diagnosed with EuDKA with high anion gap metabolic acidosis, a medical emergency similar to diabetic ketoacidosis. The normal blood glucose levels in EuDKA can mask the condition, which poses a conundrum for physicians in the emergency department/intensive care units as it may delay diagnosis and treatment, worsening the outcomes. To mitigate this risk, SGLT2i should be stopped 3-4 days before planned surgery with appropriate adjustments to the insulin regimen.

Modern-Day Therapeutics and Ongoing Clinical Trials against Type 2 Diabetes Mellitus: A Narrative Review

OBJECTIVES

Diabetes Mellitus (DM) is a global health concern that affects millions of people globally. The present review aims to narrate the clinical guidelines and therapeutic interventions for Type 2 Diabetes Mellitus (T2DM) patients. Furthermore, the present work summarizes the ongoing phase 1/2/3 and clinical trials against T2DM.

METHODS

A meticulous and comprehensive literature review was performed using various databases, such as PubMed, MEDLINE, Clinical trials database (https://clinicaltrials.gov/), and Google Scholar, to include various clinical trials and therapeutic interventions against T2DM.

RESULTS

Based on our findings, we concluded that most T2DM-associated clinical trials are interventional. Anti-diabetic therapeutics, including insulin, metformin, Dipeptidyl Peptidase-4 (DPP-4) inhibitors, Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RAs), and Sodium- Glucose cotransporter-2 (SGLT-2) inhibitors are frontline therapeutics being clinically investigated. Currently, the therapeutics in phase IV clinical trials are mostly SGLT-2 inhibitors, implicating their critical contribution to the clinical management of T2DM.

CONCLUSION

Despite the success of T2DM treatments, a surge in innovative treatment options to reduce diabetic consequences and improve glycemic control is currently ongoing. More emphasis needs to be on exploring novel targeted drug candidates that can offer more sustained glycemic control.

Trends in anti-diabetic medication use, severe hyperglycaemia and severe hypoglycaemia among American Indian and Alaska Native Peoples, 2009-2013

AIMS

Type 2 diabetes (T2D) and its complications disproportionally affect American Indian and Alaska Native (AI/AN) peoples. Prescribing decisions for anti-diabetic medications are complicated and require balancing medication benefits, costs and side effects. Little is known about trends in anti-diabetic medication use as well as acute diabetes complications among AI/AN adults. Here, we examined patterns and trends in anti-diabetic medication use and rates of hospital admissions or emergency department (ED) visits due to severe hypoglycaemia and hyperglycaemia among AI/AN adults with T2D.

MATERIALS AND METHODS

We conducted a retrospective analysis of Indian Health Service (IHS) Improving Health Care Delivery Data Project. A total of 39 183 AI/AN adults aged ≥18 years with T2D who used IHS or Tribal health services during any of the fiscal years (FYs) 2009-2013 were included. Utilization rates of each class of anti-diabetic medications and rates of severe hypoglycaemia and severe hyperglycaemia in emergency room and/or inpatient discharge diagnoses were calculated for each year. Longitudinal statistical models were fitted to examine time trends of anti-diabetic medication use and complications.

RESULTS

During 2009-2013, use of metformin (56.0%-60.5%), insulin (31.4%-35.9%) and dipeptidyl peptidase-4 inhibitors (1.4%-9.0%) increased, whereas the use of sulfonylureas (40.3%-32.9%) and thiazolidinediones (TZDs, 31.6%-8.8%) decreased significantly. Trends in severe hypoglycaemia (1.6%-0.8%) and severe hyperglycaemia (2.0%-1.6%) declined gradually.

CONCLUSIONS

There were significant changes in the utilization of different anti-diabetic medication classes during 2009-2013 among AI/AN adults with T2D. Concurrently, there were significant reductions in severe hypoglycaemia and severe hyperglycaemia.

SQuID (subcutaneous insulin in diabetic ketoacidosis): Clinician acceptability

BACKGROUND

We previously implemented the SQuID protocol (subcutaneous insulin in diabetic ketoacidosis [DKA]) demonstrating safe, effective treatment of low- to moderate-severity DKA in a non-intensive care unit setting. Since success and sustainability of interventions rely on staff buy-in, we assessed acceptability of SQuID among emergency department (ED) and inpatient clinicians.

METHODS

We conducted a cross-sectional study in an urban academic hospital (March 2023-November 2023), surveying ED nurses (RNs) and physicians (MDs) and floor RNs and MDs treating patients on SQuID via emailed survey links. Clinicians could only take the survey once. We used Sekhon's Theoretical Framework of Acceptability, validated for staff acceptability of a new intervention, assessing eight domains with 5-point Likert responses. Clinicians were asked about prior experience with SQuID, and we assessed ED MD and RN preference (SQuID vs. intravenous [IV] insulin). Surveys included free-text boxes for comments. We present descriptive statistics including proportions with 95% confidence interval and medians with interquartile ranges (IQRs) and conducted thematic analysis of free-text comments.

RESULTS

Our overall response rate (107/133) was 80% (34/42 ED RNs, 13/16 floor RNs, 47/57 ED MDs, 13/17 floor MDs), with first-time users of SQuID ranging from 7.7% (hospitalist MDs) to 35.3% (ED RNs) of participants. ED clinicians preferred SQuID over IV insulin (67% vs. 12%, 21% no preference). Acceptability was high across all domains and clinician types (median 4, IQR 4-5). Overall percentage of positive responses (4s and 5s) across domains was 92% (ED RNs [89%], floor RNs [89%], ED MDs [97%], floor MDs [87%]). We identified several themes among participant comments.

CONCLUSIONS

Acceptability was high across clinician types; 65% of ED clinicians preferred SQuID to IV insulin. Clinicians liked SQuID (affective attitude), found it easy to use (burden), were confident in its use (self-efficacy), felt that it improved outcomes (perceived effectiveness), found that it was fair to patients (ethicality), found that it made sense (intervention coherence), and found that it did not interfere with other activities (opportunity cost).

Perioperative Care of Patients Using Wearable Diabetes Devices

The increasing prevalence of diabetes mellitus has been accompanied by a rapid expansion in wearable continuous glucose monitoring (CGM) devices and insulin pumps. Systems combining these components in a "closed loop," where interstitial glucose measurement guides automated insulin delivery (AID, or closed loop) based on sophisticated algorithms, are increasingly common. While these devices' efficacy in achieving near-normoglycemia is contributing to increasing usage among patients with diabetes, the management of these patients in operative and procedural environments remains understudied with limited published guidance available, particularly regarding AID systems. With their growing prevalence, practical management advice is needed for their utilization, or for the rational temporary substitution of alternative diabetes monitoring and treatments, during surgical care. CGM devices monitor interstitial glucose in real time; however, there are potential limitations to use and accuracy in the perioperative period, and, at the present time, their use should not replace regular point-of-care glucose monitoring. Avoiding perioperative removal of CGMs when possible is important, as removal of these prescribed devices can result in prolonged interruptions in CGM-informed treatments during and after procedures, particularly AID system use. Standalone insulin pumps provide continuous subcutaneous insulin delivery without automated adjustments for glucose concentrations and can be continued during some procedures. The safe intraoperative use of AID devices in their hybrid closed-loop mode (AID mode) requires the CGM component of the system to continue to communicate valid blood glucose data, and thus introduces the additional need to ensure this portion of the system is functioning appropriately to enable intraprocedural use. AID devices revert to non-AID insulin therapy modes when paired CGMs are disconnected or when the closed-loop mode is intentionally disabled. For patients using insulin pumps, we describe procedural factors that may compromise CGM, insulin pump, and AID use, necessitating a proactive transition to an alternative insulin regimen. Procedure duration and invasiveness is an important factor as longer procedures increase the risk of stress hyperglycemia, tissue malperfusion, and device malfunction. Whether insulin pumps should be continued through procedures, or substituted by alternative insulin delivery methods, is a complex decision that requires all parties to understand potential risks and contingency plans relating to patient and procedural factors. Currently available CGMs and insulin pumps are reviewed, and practical recommendations for safe glycemic management during the phases of perioperative care are provided.

Effectiveness of Balanced Electrolyte Solution vs Normal Saline in the Resuscitation of Adult Patients with Diabetic Ketoacidosis: An Updated Systematic Review and Meta-analysis

AIM AND BACKGROUND

Fluid resuscitation is the first-line treatment for patients with diabetic ketoacidosis (DKA). However, the optimal choice of resuscitative fluid remains controversial. This study aims to evaluate the impact of balanced electrolyte solution (BES) compared to 0.9% sodium chloride (NS) on various physiological and clinical outcomes in adult DKA patients.

MATERIALS AND METHODS

An extensive search of electronic databases, including Embase, PubMed, Cochrane Library, Web of Science, and Google Scholar, was conducted to select studies that directly compared BES and NS in adult DKA patients. This systematic review and meta-analysis included nine studies, comprising both randomized controlled trials and retrospective studies. Combined estimates were expressed as mean differences (MDs) with 95% confidence intervals (CIs). The primary outcomes were time to resolution of DKA and length of hospital stay. The secondary outcomes were post-resuscitation chloride and bicarbonate levels and adverse events.

RESULTS

No significant difference was observed between BES and NS in the time to DKA resolution (MD: -1.63; 95% CI: -7.66-4.41; p = 0.60) or length of hospital stay (MD: -0.07; 95% CI: -0.44-0.31; p = 0.73). However, BES resulted in significantly higher post-resuscitation bicarbonate levels (MD: 1.63; 95% CI: 0.86-2.39; p < 0.001) and lower post-resuscitation chloride levels (MD: -2.37; 95% CI: -3.56 to -1.19; p < 0.001).

CONCLUSION

The use of BES is associated with improved post-resuscitation electrolyte balance and preventing hyperchloremic metabolic acidosis in DKA patients. While BES may offer some biochemical advantages, both BES and NS are safe for treating DKA.

HOW TO CITE THIS ARTICLE

Gupta P, Nasa P, Shahabdeen SM. Effectiveness of Balanced Electrolyte Solution vs Normal Saline in the Resuscitation of Adult Patients with Diabetic Ketoacidosis: An Updated Systematic Review and Meta-analysis. Indian J Crit Care Med 2025;29(1):65-74.

SQuID (subcutaneous insulin in diabetic ketoacidosis) II: Clinical and operational effectiveness

OBJECTIVE

We previously demonstrated safe treatment of low- to moderate-severity (LTM) diabetic ketoacidosis (DKA) using the SQuID protocol (subcutaneous insulin in DKA) in a non-intensive care unit (ICU) observation setting, with decreased emergency department length of stay (EDLOS). Here, we expand eligibility to include sicker patients and admission to a regular medical floor and collected more detailed clinical data in a near-real-time fashion.

METHODS

This is a real-world, prospective, observational cohort study in an urban academic hospital (March 4, 2023-March 4, 2024). LTM DKA patients were treated with IV insulin (floor or ICU) or on SQuID. We compare fidelity (time to glargine and dextrose-containing fluids), safety (rescue dextrose for hypoglycemia), effectiveness (time to anion gap closure, time on protocol), and operational efficiency (time to bed request, EDLOS, and ICU admission rate since implementation of the protocol).

RESULTS

Of 84 patients with LTM DKA, 62 (74%) of were treated with SQuID and 22 (26%) with IV insulin. Fidelity was high in both groups. Rescue dextrose was required in five (8%) versus four (18%) patients, respectively (difference 9%, -31% to 10%). Compared to the IV insulin group, time to anion gap was 1.4 h shorter (95% CI -3.4 to 0.2 h) and time on protocol was 10.4 h shorter (95% CI -22.3 to -5.0 h) in SQuID patients. Median EDLOS was lower in the SQuID cohort 9.8 h (IQR 6.0-13.6) than the IV floor cohort 18.3 h (IQR 13.4-22.0 h), but longer than the overall IV insulin cohort. Since inception of SQuID, ICU admission rate in LTM DKA has decreased from 54% to under 21%.

CONCLUSIONS

In this single-center study, we observed excellent fidelity, equivalent or superior safety, and clinical and operational effectiveness with SQuID compared to IV insulin. The SQuID protocol has become the de facto default pathway for treatment of LTM DKA. Since inception of SQuID, ICU admissions in LTM DKA have decreased 33%.

Revisiting Diabetic Ketoacidosis (DKA) Fluid Management: Should Normal Saline Be Used?

Background Diabetic ketoacidosis (DKA) is a common and serious complication of diabetes, often requiring hospitalization and intensive care. Fluid resuscitation is a cornerstone of DKA management, with traditional guidelines recommending isotonic normal saline (NS) for initial volume replacement. Recent studies, however, suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis. This study investigates the effects of large-volume NS resuscitation on clinical outcomes in DKA management, comparing it to other fluids, such as lactated Ringers (LR). Objective To evaluate whether large-volume resuscitation with isotonic normal saline (NS) is associated with prolonged ICU length of stay (LOS), increased time on insulin infusion, and higher rates of non-anion gap metabolic acidosis in patients with DKA. Materials and methods This was a single-center, retrospective, observational study conducted at Naples Comprehensive Healthcare System. We reviewed electronic medical records of patients diagnosed with DKA, defined by pH <7.3, bicarbonate <18, and anion gap >12. The primary outcome was ICU LOS, and secondary outcomes included overall length of stay, insulin infusion duration after DKA resolution, and incidence of non-anion gap metabolic acidosis after DKA resolution. Patients were grouped by the amount of NS received during resuscitation: 0L, 1L, 2L, and ≥3L. Statistical analyses included analysis of variance (ANOVA), t-tests, and chi-square tests to compare outcomes between groups. Results A total of 109 patients were included in the study. The mean age was 51.34 years, and the cohort consisted of 43.1% females and 56.9% males. There was no significant difference in ICU LOS between patients who received 0L and 1L of NS. However, patients who received 2L (p=0.0249) and ≥3L (p=0.00065) had significantly longer ICU LOS compared to those who received 0L of NS. No significant difference in overall LOS was also observed across all groups (p=0.894). Patients who received ≥3L of NS had a significantly longer duration of insulin infusion compared to those who received 0L (p=0.0101) after DKA anion gap closure while a significant increase in the incidence of non-anion gap acidosis after DKA resolution was observed in patients receiving ≥2L of NS (p=0.0000). Conclusion This study suggests that large-volume resuscitation with isotonic NS in DKA patients is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis. These findings support the use of balanced crystalloids, such as lactated Ringers, for initial resuscitation in DKA patients, as they may reduce the risk of complications related to hyperchloremia and improve clinical outcomes. Further prospective studies are needed to confirm these findings and guide fluid management protocols in DKA.