Evaluation of hyperglycaemic emergency admissions to a major tertiary centre over a two-year period

Abstract

Diabetic ketoacidosis (DKA), hyperosmolar hyper-glycaemic state (HHS) and mixed presentations are diabetes emergencies. We performed a retrospective cohort study to examine the demographics, clinical characteristics, treatment approaches and outcomes of participants requiring inpatient management for DKA and/or HHS at Prince of Wales Hospital, a tertiary facility in Sydney, Australia, between May 2022 and April 2024.

Definitions of HHS and DKA based on the American Diabetes Association (ADA) consensus report were used.¹ Individuals with combined DKA and HHS had to meet both DKA and HHS criteria. We extracted demographic data from each participant during the index hospitalisation, the type of treatment protocol used (DKA, HHS) alongside the outcome and complications of treatment. Outcomes and complications of treatment included the presence of electrolyte derangements (corrected hyponatremia, hypokalaemia), hypoglycaemia, intensive care unit admission, length of stay and mortality. The SPSS statistics software (version 24.0; IBM) was used to undertake all statistical analyses. Independent sample t-tests were undertaken for continuous data and Pearson's chi-squared tests for categorical data. Adjustment for multiple comparisons were not undertaken. p < 0.05 defined statistical significance.

In total, 85 persons were admitted with hyperglycaemic emergencies across the 2-year period. A total of 46/85 (54%) had DKA, 15/85 (18%) had HHS, while 24/85 (28%) had mixed HHS and DKA. Individuals with HHS were older, 64.7 ± 14.5 years, than those with DKA, 42.3 ± 18.2 (p < 0.0001) or mixed DKA/HHS, 53.1 ± 19.2 (p < 0.05). They also had a higher HbA1c, 14.2 ± 3.3% [132 ± 13] than those with DKA, 11.6 ± 3.2% [103 ± 11] (p < 0.01) or mixed DKA/HHS, 11.7 ± 2 [104 ± 0.9] (p < 0.05). Six of 85 (8%) individuals had a new diagnosis of Type 1 Diabetes Mellitus (T1DM), while three of 85 (4%) individuals who presented with HHS had a new diagnosis of Type 2 Diabetes Mellitus (T2DM). Four of 46 (9%) individuals had euglycaemic DKA. A total of 44/85 (52%) individuals had T1DM, 34/85 had T2DM, while seven of 85 (8%) had Type 3c Diabetes Mellitus.

In the mixed DKA/HHS subgroup (n = 24), 19/24 (79%) individuals were treated with the DKA protocol, while five of 24 (20.8%) were treated with the HHS protocol. Both the DKA (0.1 units/kg/h) and HHS protocols (0.05 units/kg/h) are fixed insulin rates based on body weight. The HHS insulin infusion starting dose (0.05 units/kg/h) was amended from the 2009 consensus guidelines. It was at the discretion of the treating endocrinologist to decide which protocol to follow.

In general, individuals treated with the HHS protocol were older, had slightly worse initial renal function and were slightly less acidotic and ketotic (Table 1). Individuals treated with the DKA protocol had slightly longer length of stay. The rates of hypokalaemia were similar regardless of the protocol used, but the rates of hyponatremia were higher in participants treated with the DKA protocol. Among some clinicians, the administration of basal insulin while on fixed-rate intravenous insulin infusion has led to concerns about hypoglycaemia or hypokalaemia.² Several studies have since reported that co-administration of low-dose basal insulin during insulin infusion reduces the time to DKA resolution without increasing the risk of hypoglycaemia.^3-5 Similarly, only a single case of hypoglycaemia was identified in our study following treatment with the DKA protocol. While the sample size was small, it is reassuring that the gentler HHS protocol can be used to treat mixed DKA/HHS with minimal adverse events, potentially resulting in a lower rate of electrolyte complications.

Our study has several limitations. As it was conducted at a single tertiary hospital with a small cohort, the findings may not be extrapolated to all participants. Additionally, we only reviewed participants who presented through the Emergency Department and were admitted under Endocrinology. Although it is unlikely, we cannot fully exclude the possibility that some participants with hyperglycaemic emergencies were admitted under a different specialty.

In conclusion, in a small cohort of mixed DKA/HHS participants, treatment with either the HHS or DKA protocol did not result in substantially different outcomes. Hypokalemia and hyponatremia are common complications in all subtypes of hyperglycaemic emergencies, and enhanced recognition is necessary to prevent these issues. Larger studies, informed by the more recent 2024 ADA guidelines,⁶ are required to determine the optimal IV insulin infusion regimens for participants presenting with mixed DKA/HHS.

There was no external funding for this study.

The authors have no conflict of interest to declare.