The importance of hyperosmolarity in diabetic ketoacidosis

• Published in: Diabetic medicine Vol. 37; no. 12; pp. 2001 - 2008
• Main Authors: Blank, S. P., Blank, R. M., Ziegenfuss, M. D.
• Format: Journal Article
• Language: English
• Published: England Wiley Subscription Services, Inc 01.12.2020
• Subjects: Acidosis; Diabetes; Diabetes mellitus; Diabetic ketoacidosis; Intensive care; Intensive care units; Ketoacidosis; Mechanical ventilation; Mortality; Osmolarity; Osmotic pressure; Population studies; Prognosis; Renal failure
• ISSN: 0742-3071; 1464-5491
• DOI: 10.1111/dme.14277

Aim Diabetic ketoacidosis is a hyperglycaemic emergency that is often treated in intensive care units (ICUs) despite having a low mortality and good prognosis. Current risk stratification is based primarily on acidosis, but it has been suggested that hyperosmolarity may also be an important marker of increased severity. Our aim was to evaluate the relationship between raised serum osmolarity and adverse clinical outcomes in ICU admissions for ketoacidosis. Methods Retrospective review of prospectively collected data for adult admissions with ketoacidosis in the Australian and New Zealand Intensive Care Society Adult Patient Database over a 15‐year period (2004–2018). Exclusions were readmissions and records with critical missing data. Serum hyperosmolarity was defined as > 320 mosm/l. The primary outcome was hospital mortality; secondary outcomes were ICU mortality and other adverse clinical events. Results Some 17 379 admissions were included in the study population. People with hyperosmolarity had fourfold increased mortality, a higher incidence of renal failure and need for mechanical ventilation, and prolonged ICU and hospital length of stay. The relationship with mortality remained highly significant even after adjusting for severity of acidosis, hospital type, year of admission, time to ICU, and a modified Australia and New Zealand Risk of Death propensity score. Conclusions Although adults with ketoacidosis have a good prognosis overall, hyperosmolarity was independently associated with a significantly higher incidence of multiple adverse outcomes including mortality. Whether or not this is directly causal, it may have practical applications to improve risk stratification and identify individuals at risk of adverse outcomes. What’s new? The study uses high‐volume, multicentre data to characterize the relationship between hyperosmolarity and outcomes in adults with diabetic ketoacidosis. In an intensive care unit population, people with hyperosmolarity had a significant increase in mortality, as well as multiple adverse clinical sequelae. Hyperosmolarity may be useful clinically as a risk stratification tool to identify individuals at increased risk of adverse outcomes. Further research is required using laboratory values at hospital presentation to prospectively validate these results and better determine the threshold for increased risk.