Published online Jan 15, 2019. doi: 10.4239/wjd.v10.i1.57
Peer-review started: August 29, 2018
First decision: October 26, 2018
Revised: December 10, 2018
Accepted: December 29, 2018
Article in press: December 30, 2018
Published online: January 15, 2019
Diabetic ketoacidosis (DKA) is a common reason for hospitalization in patients with diabetes. It results in significant morbidity, mortality, and financial burden. Research and quality improvement efforts have been put forth to investigate the triggers and risk factors associated with ketoacidosis to prevent initial episode of DKA and minimize recurrence. In the meantime, the standard of care in management of DKA has been more clearly defined attention to serum glucose levels, electrolytes, acidosis and diligent evaluation for and treatment of the underlying etiology. Together, these advances resulted in significant reduction of mortality associated with DKA over the years. Nevertheless, many aspects of care for DKA patients remains unanswered, including severity stratification and appropriate level of care. Many institutions continue to accept patients with DKA to the intensive care unit (ICU) due to frequent electrolyte and glucose monitoring and meticulous insulin titration. Minimizing financial burden and hospital acquired complications associated with frequent and prolonged ICU stay is the subject of current and future investigations.
Tolerance of oral diet is regarded as a marker for resolution of ketoacidosis in DKA patients. Its administration is often postponed until biochemical confirmation of the resolution of ketoacidosis due to fear of unpredictable glucose and electrolyte changes. We hypothesized that allowance of on demand oral nutrition in DKA patients is safe and has a potential to decrease the length of hospitalization.
We aim to compare the mortality, rate of complications, and length of stay between DKA patients receiving oral nutrition before and after the first 24 h of ICU admission.
Retrospective data collection was conducted establishing the demographics, initial biochemical characteristics, and outcomes of patients admitted to our single academic medical center. Outcomes included common complications of DKA, 28- and 90-d mortality, and length of ICU and hospital stay. Bivariate analysis was then performed comparing these variables between the two subgroups defined by the timing of their first oral intake.
The timing of oral nutrition in DKA patients was heterogenous between different care teams with 52.3% of patients restarting oral intake in the first day of admission. This did not result in increased mortality (2.34% vs 0.78%, P = 0.62) or rate of complications such as hyperkalemia (0.56 vs 0.43, P = 0.37), hypoglycemia (0.97 vs 1.54, P = 0.18), or severe acidosis (0.04 vs 0.20, P = 0.18). Despite having similar overall illness severity and severity of DKA itself, the DKA patients who received oral nutrition in the first 24 h of their admission had a shorter ICU (1.38 vs 3.12, P = 0.0002) and (4.16 vs 8.35 P = 0.0001) hospital stay.
Early oral nutrition (defined as oral intake in the first 24 h) administered on demand in patents admitted to ICU with DKA has a potential to safely reduce the length of stay.
The study introduces the possibility of early oral nutrition in DKA to improve the length of stay. Further prospective randomized investigation is necessary to validate this finding.