TABLE 1.
Admissions for Diabetic Ketoacidosis Inpatient With Type 1 Diabetes and Addison’s Disease
| Clinical and Outcome Variables of Interest | High-Dose Glucocorticoids | Maintenance/Moderate Glucocorticoids | |||||
|---|---|---|---|---|---|---|---|
| Admission 1 | Admission 2 | Group | Admission 3 | Admission 4 | Admission 5 | Group | |
| Findings on presentation | |||||||
| Precipitating factor | Insulin omission | Insulin omission | Insulin omission | Insulin omission | Insulin omission | Insulin omission | Insulin omission |
| Mental status | Alert and oriented | Alert and oriented | Alert and oriented | Alert and oriented | Alert and oriented | Alert and oriented | Alert and oriented |
| Temperature (°C) | 36.7 | 36.4 | 36.6 | 36.3 | 36.4 | 36.8 | 36.5 |
| Blood pressure (mm Hg) | 111/72 | 100/58 | 106/65 | 101/70 | 112/81 | 94/62 | 102/71 |
| Heart rate (beats/min) | 95 | 131 | 113 | 115 | 119 | 124 | 119 |
| Respiratory rate (per min) | 16 | 18 | 17 | 18 | 18 | 20 | 19 |
| Oxygen saturation room air (%) | 100 | 98 | 99 | 99 | 98 | 99 | 99 |
| HbA1c (%) (mmol/mol) | 13.6 (125) | 14 (130) | 13.8 (127) | 14.4 (134) | > 14 (> 130) | 12.6 (114) | > 13.5 (> 124) |
| Urine or serum ketones documented | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Serum bicarbonate (total CO2 mmol/L) | 12 | 15 | 13.5 | 12 | 12 | 12 | 12 |
| Anion gap | 31 | 29 | 30 | 27 | 29 | 27 | 28 |
| pH arterial or venous blood gas | 7.35a | 7.36a | 7.4 | 7.23 | 7.28 | 7.26 | 7.26 |
| Serum glucose (mg/dL) (mmol/L) | 438 (24.3) | 529 (29.3) | 483.5 (26.8) | 362 (20.1) | 497 (27.6) | 540 (30) | 466 (25) |
| Corrected serum sodium (mmol/L) | 141 | 136 | 138.5 | 131 | 138 | 134 | 134 |
| Serum potassium (mmol/L) | 5.6 | 4.6 | 5.1 | 5.2 | 5.8 | 5.4 | 5.5 |
| Acute Physiology and Chronic Health Evaluation II score | 2a | 4a | 3.0 | 5 | 7 | 6 | 6 |
| Insulin regimen | |||||||
| Initial bolus of regular insulin (units/kg) | 0.15 | 0.1 | 0.13 | n/ab | 0.175 | 0.1 | 0.14 |
| Initial infusion rate (units/kg/hr) | 0.1 | 0.1 | 0.1 | 0.05c | 0.1 | 0.1 | 0.08 |
| Basal insulin for transition to subcutaneous (units/kg of glargine or equivalent) | 0.15 | 0.22 | 0.19 | 0.18 | 0.18 | 0.2 | 0.19 |
| Steroid regimen | |||||||
| Total hydrocortisone (mg/d) | |||||||
| Day 1 | 120 | 150 | 135 | 20d | 55d | 30 | 35 |
| Day 2 | 60 | 70 | 65 | — | — | 40d | 40d |
| Day 3 | 20d | 20d | 20d | — | — | — | — |
| Time from arrival to first hydrocortisone dose (hr) | 18 | 10 | 14 ± 5.7 | 15 | 13 | 17 | 15 ± 2.0 |
| Fludrocortisone (mg/day) | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 | 0.1 |
| Time from arrival to first fludrocortisone dose (hr) | 18 | 61 | 39.5 ± 30.4 | 15 | 14 | 17 | 15 ± 1.5 |
| Outcomes | |||||||
| Clinically significant hypoglycemia events | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Level 1 hypoglycemia events > 1 hr apart | 1 | 1 | 1 | 0 | 1 | 1 | 0–1 |
| Hypotensive events | 0 | 0 | 0 | 0 | 0 | 1 | 0–1 |
| Time to resolution of DKA (hr) | 36 | 55 | 45.5 ± 13.4 | 16 | 13 | 7 | 12 ± 4.6 |
| DKA relapse after transition to subcutaneous insulin | No | Yes | 0–1 | No | No | No | 0 |
| ICU length of stay (hr) | 40 | 53 | 47 ± 9.2 | Not applicable | 33 | 16 | 24.5 ± 12.0 |
| Hospital length of stay (hr) | 67 | 59 | 63 ± 5.7 | 13 | 33 | 46 | 31 ± 16.6 |
| Patient left against medical advice | Yes | Yes | Yes | No | No | No | No |
DKA = diabetic ketoacidosis.
aBlood gas obtained 1–2 hr after initiating treatment with fluids and insulin; influences Acute Physiology and Chronic Health Evaluation Score calculation.
bPatient self-administered a subcutaneous bolus of 0.11 units/kg of regular insulin immediately prior to presentation.
cPatient treated with insulin infusion outside of ICU. Provider opted to use half of standard protocol rate.
dAdministered dose of hydrocortisone until time of discharge.
Group shows descriptive summary, frequency, or mean ± sd.