Abstract
BACKGROUND: No standardized nomogram has been established to reduce hypoglycemia events while optimizing clinical outcomes for patients with diabetic ketoacidosis (DKA). OBJECTIVE: To evaluate the safety and effectiveness of two DKA nomograms. METHODS: We conducted a multicenter, retrospective cohort study in adult patients (≥18 years) treated with IV insulin for DKA. Cohorts were categorized based on the insulin nomogram utilized: Standard Incremental Nomogram with Glucose-Level Evaluation (SINGLE) and Multiple Algorithm Nomogram using Insulin Change and Rate Estimate (MULTIPLE). Patients were excluded if they were experiencing pregnancy, euglycemic DKA, or hyperosmolar hyperglycemic state. The primary outcome was hypoglycemic events (BG < 70 mg/dL). Secondary outcomes included time to DKA resolution and DKA recurrence. RESULTS: A total of 234 patients were included (SINGLE n = 117, MULTIPLE n = 117). Hypoglycemia occurred in eight patients in the MULTIPLE group (6.8%) versus 25 patients in the SINGLE group (21.4%) (P< 0.01) after controlling for confounders, hypoglycemia remained highest in the SINGLE cohort versus the MULTIPLE cohort (OR 3.0 [95% CI 1.2-7.2], P < 0.01). After controlling for confounders, hypoglycemia remained highest in the SINGLE cohort versus the MULTIPLE cohort (OR 3.0 [95% CI 1.2-7.2], P < 0.01). Significant differences were not observed between the two nomograms in time to DKA resolution (16.4 hours [IQR 10.2-28.3] vs 16.1 [IQR 10.0-22.8], P = 0.19), recurrence rates (11.1% vs 15.4%, P = 0.34) or ICU LOS (P = 0.06). CONCLUSION: The MULTIPLE nomogram had fewer hypoglycemia events with no difference in time to DKA resolution. Additional studies are needed to evaluate varying nomograms to determine the optimal approach.