Poster Presentation ESA-SRB-ANZBMS 2024 in conjunction with ENSA

Management protocols for diabetic ketoacidosis in Australian hospitals are diverse and often deviate from international guidelines (#557)

Lisa M Raven 1 2 3 , William Lever 4 5 , Richard MacIsaac 6 7 8 , Jerry R Greenfield 1 2 3 , Adam Dean 6 9 , Mark Plummer 4 5 , Mahesh Umapathysivam 4 10
  1. Department of Endocrinology, St Vincent's Hospital, Darlinghurst, NSW, Australia
  2. Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
  3. School of Clinical Medicine, St Vincent’s Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
  4. Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
  5. Department of Intensive Care, Royal Adelaide Hospital, Adelaide, South Australia, Australia
  6. University of Melbourne, Melbourne, Victoria, Australia
  7. Department of Endocrinology, St Vincent's Hospital Melbourne , Melbourne, Victoria, Australia
  8. Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Melbourne, Victoria, Australia
  9. Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  10. Department of Endocrinology, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Diabetic ketoacidosis (DKA) is a hyperglycaemic emergency requiring insulin administration, hydration, electrolyte replacement and treatment of the underlying precipitant. Insulin administration is highly protocolised with either variable rate intravenous infusion (insulin rate titrated based on glucose level) or fixed rate intravenous infusion (insulin rate is constant with glucose titrated). International guidelines recommend fixed rate insulin infusions.1,2 However the limited evidence comparing these two modalities suggests variable and fixed rate insulin infusions result in similar time to resolution of DKA.3-5

 

Aim: To characterise DKA management protocols used in Australian hospitals.

 

Methods: An online survey of Australian endocrinologist and intensive care physicians between May and July 2024.

 

Results: A summary of DKA protocols from 30 hospitals around Australia were collected. There was wide variation including fixed (n=12), variable (n=14) and combination (n=5) insulin infusion protocols (Table 1). Of those that used fixed or combination protocols, one had a fixed starting insulin rate that was independent of patient weight (4 units/hour); the remaining protocols determined rate based on units/kg, most commonly 0.1 units/kg or 0.05 units/kg. Most (77%) respondents had worked at another hospital that had a different DKA management protocol. There was a 50% split (n=14 each) in personal preference for fixed or variable rate infusion with 4 respondents not having a preference.

Most (68%) protocols defined resolution of DKA, most commonly based on pH level (71%) and/or ketone level (86%). A pH of >7.3 was the most common (83%) threshold for resolution. The ketone threshold for DKA resolution varied: 14% (n=2) used <1.0 mmol/L, 79% (n=11) used <0.6 mmol/L, and 7% (n=1) used <0.3 mmol/L.

 

Conclusion: There is substantial variation in insulin regimens and criteria for resolution in DKA management protocols across Australian hospitals, and clinician preference was diverse. This likely reflects the lack of high-quality evidence to guide practice.

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  1. American Diabetes Association Professional Practice C. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024. Diabetes Care 2024;47(Suppl 1):S295-S306. DOI: 10.2337/dc24-S016.
  2. Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia 2024. DOI: 10.1007/s00125-024-06183-8.
  3. Bohach N, Moorman JM, Cunningham B, Mullen C, Fowler M. A Comparison of Variable Versus Fixed Insulin Infusion Rate on Resolution of Diabetic Ketoacidosis. Am J Ther 2023;30(3):e179-e185. DOI: 10.1097/MJT.0000000000001619.
  4. Lorenson JL, Cusumano MC, Stewart AM, Buhnerkempe MG, Sanghavi D. Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study. Int J Pharm Pract 2019;27(4):380-385. DOI: 10.1111/ijpp.12525.
  5. Koneshamoorthy A, Epa DS, O'Neal DN, Lee MH, Santamaria JD, MacIsaac RJ. Outcomes associated with a variable rate insulin infusion diabetic ketoacidosis protocol. J Diabetes Complications 2024;38(3):108702. DOI: 10.1016/j.jdiacomp.2024.108702.