Diabetic ketoacidosis: new onset cases were common.

Clinical bottom line (level 4)

  1. Diabetic ketoacidosis occurred in patients with type I or II diabetes.
  2. Around a quarter of patients with DKA had new onset diabetes.
  3. The commonest causes of DKA were infection, treatment error and 'unknown'.
Westphal : American Journal of Medicine 1996; 101: 19-24
Expires October 2003

The study

Case series with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: intensive care unit, acute hospital, USA, 1987-93

226 patients (aged mean 35 years, 69% male) diabetic ketoacidosis (defined as glucose 14 or more, bicarbonate 15 mmol/l or less, pH 7.35 or less, ketonaemia and elevated anion gap)

Excluded if
  • < 18 years old





    • Outcomes studied:
  • type I
  • type II
  • new onset
  • unknown cause of DKA
  • cause: omission of treatment
  • cause: infection
  • cause: pancreatitis
  • cause: myocardial infarction
  • cause: GI bleed

      • Type I diabetes: continuous insulin therapy and a prior history of DKA
      • Type II diabetes: managed previously with diet or oral agent and with no known history of DKA

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    type I ? 106/226 47%
    (40% to 53%)
    type II ? 58/226 26%
    (20% to 31%)
    new onset ? 62/226 27%
    (22% to 33%)
    unknown cause of DKA ? 82/226 36%
    (30% to 43%)
    cause: omission of treatment ? 64/226 28%
    (22% to 34%)
    cause: infection ? 60/226 27%
    (21% to 32%)
    cause: pancreatitis ? 7/226 3.1%
    (0.8% to 5.4%)
    cause: myocardial infarction ? 2/226 0.9%
    (0.0% to 2.1%)
    cause: GI bleed ? 2/226 0.9%
    (0.0% to 2.1%)

    Comments

    1. This manuscript is one of the important documents showing that the traditional concept of diabetic ketoacidosis being the hallmark of Type 1 (permanent insulin deficient) diabetes is incorrect.

    Citation

    1. Westphal SA, : The occurrence of diabetic ketoacidosis in non-insulin-dependent diabetes and newly diagnosed diabetic adults. American Journal of Medicine 1996; 101: 19-24
    Contributor: Chris Ball and Clare Wotton, July 2000
    Reviewer: Jon Levine

    Clinical Question.
    Patient DKA
    Intervention or Exposure prevalence
    Outcome new onset, causes