SAT-675 Relapsing Diabetic Ketoacidosis During Stepdown from Intensive Care Unit

BACKGROUND: DKA is a life-threatening and expensive complication of diabetes, costing $5.1 billion annually. Recurrent DKA accounts for ~ 20% of DKA admissions. Here we present 2 patients with relapsing DKA during transition from ICU to the medical floor. CASE-1: A 61-year-old previously healthy man presented with 3-day of generalized weakness and nausea. Review of systems was positive for polyuria and polydipsia. His brother has T2D. Examination: afebrile, HR 166/min, BP 146/104mmHg, dry oropharynx. Labs: Serum glucose 689mg/dl, Na 126mmol/L(136-145mmol/dl), K 4.8mmol/L(3.5-5.1mmol/L), Cl 78mmol/L(98-107mmol/L), bicarbonate 8mmol/L(21-32mmol/L), creatinine 4 mg/dl(0.7-1.3mg/dl), Anion gap(AG) >20(5-20), HCT 57.6%(38.8-48%), A1c 10.4%, c-peptide 1.5ng/ml(0.8-3.8ng/ml). Urine: ketones++. A diagnosis of new-onset diabetes presenting with DKA was made. Patient was admitted to ICU and insulin and saline were infused per protocol. Because the AG closed promptly and bicarbonate improved to 20mmol/L, insulin drip was stopped in the ICU and patient was transferred to medical floor. Evaluation on the medical floor 4 hours later showed bicarbonate of 14 mmol/L and AG >20. Due to deterioration, patient returned to the ICU for management of recurrent DKA. After stabilization in ICU, patient returned to the medical floor and was successfully discharged on basal-bolus insulin the next day. CASE-2: A 35-year-old with history of T2D presented with 1-day of nausea and vomiting. Review of systems was positive for polyuria and polydipsia. Home medications: metformin, glipizide and glargine. Examination: afebrile, HR 104/min, BP 154/97mmHg and tender abdomen. Labs: Serum glucose 411mg/dl, Na 137mmol/L, K 4.6mmol/L, Cl 103mmol/L, bicarbonate 17mmol/L, Creatinine 0.9 mg/dl, AG 22, BHB 6.98 mmol (0.0-0.89mmol), A1c 9%. Patient was admitted to ICU for DKA management. Bicarbonate improved to 20 mmol/L, so insulin drip was stopped in the ICU and patient was transferred to medical floor. Evaluation after 6 hours showed bicarbonate of 17mmol/L and AG of 20. Because of the decreasing bicarbonate and increasing AG, a diagnosis of recurrent DKA was made and prompt insulization was restarted. Patient responded to the regimen and was discharged home on basal-bolus two days later. CONCLUSION: Recurrent DKA due to abrupt cessation of IV insulin prolonged these patients’ hospitalization. The practice of overlapping IV insulin with SQ insulin for >30 min prevents dissipation of insulin action during resolution of DKA. Half-life of IV insulin is 3 min, so SQ insulin must be given before cessation of the insulin drip to prevent the relapse. Omission of this practice, as occurred in these patients unfortunately, caused relapse in DKA and prolonged hospitalization. Education of ICU staff on proper insulin management is warranted to prevent healthcare cost: the cost of a DKA hospitalization was $26,566 in 2014.