(295) A Pre-Post Study of Updates to a Diabetic Ketoacidosis/Hyperosmolar Hyperglycemic Syndrome Protocol

Introduction: Endocrine emergencies including diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) lead to increased morbidity and hospital admissions. The 2009 American Diabetes Association (ADA) consensus statement recommends insulin infusion initiation, fluid and potassium management with goals of resolving acidosis and reducing serum glucose. Based on more recent studies, our institutional protocol for DKA/ HHS underwent changes including a nurse titrated insulin infusion (in place of a non-titratable infusion for the first 6 hours), elimination of the initial insulin bolus, IV fluid changes from 0.9% sodium chloride to lactated Ringer’s solution and more aggressive potassium repletion, with the goal of faster resolution of acidosis and prevention of hyperchloremic acidosis and hypokalemia.

The purpose of this study was to evaluate the efficacy and safety of the updated DKA/HHS protocol (new protocol, NP) compared to the pre-change protocol (old protocol, OP).

Methods: This was a retrospective, IRB approved pre-post study that included adult patients with a diagnosis of DKA, euglycemic DKA or HHS initiated on the DKA/ HHS protocol pre (May 2021-June 2022) and post change implementation (December 2022-February 2023). Primary efficacy endpoints included % patients with DKA/HHS resolution along with time to resolution. Secondary endpoints included % patients with hypoglycemia, and % hypokalemic episodes in each group.

Results: Fifteen patients were included in the OP and 50 patients were included in the NP groups. Resolution of DKA/HHS occurred in 93% OP patients vs 98% NP patients, while mean time to DKA/HHS resolution was longer in the OP patients (22.9 hours vs 17 hours). Hypoglycemia (blood glucose < 70 mg/dL) occurred in more OP patients (20% vs 10%), as did severe hypoglycemia (blood glucose < 54 mg/dL) (6.7% vs 2%). There were fewer hypokalemic episodes per patient in the OP group (26.7% vs 36%).

Conclusions: The updated institutional protocol led to faster time to DKA/HHS resolution in more patients and fewer hypoglycemic episodes. More hypokalemic episodes in the NP group may be attributed to elimination of suggested initial potassium order. Limitations include small study size, retrospective nature and variable lab timing for DKA/HHS resolution evaluation.