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Prevalence of Ketosis, Ketonuria, and Ketoacidosis During Liberal Glycemic

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Prevalence of Ketosis, Ketonuria, and Ketoacidosis During Liberal Glycemic Luethi et al. Critical Care (2016) 20:297 DOI 10.1186/s13054-016-1462-7 RESEARCH Open Access Prevalence of ketosis, ketonuria, and ketoacidosis during liberal glycemic control in critically ill patients with diabetes: an observational study Nora Luethi1, Luca Cioccari1,2, Marco Crisman1,3, Rinaldo Bellomo1,4, Glenn M. Eastwood1 and Johan Mårtensson1,5* Abstract Background: It is uncertain whether liberal glucose control in critically ill diabetic patients leads to increased ketone production and ketoacidosis. Therefore, we aimed to assess the prevalence of ketosis, ketonuria and ketoacidosis in critically ill diabetic patients treated in accordance with a liberal glycemic control protocol. Methods: We performed a prospective observational cohort study of 60 critically ill diabetic patients with blood and/or urine ketone bodies tested in ICU. All patients were treated according to a liberal glucose protocol targeting a blood glucose level (BGL) between 10 and 14 mmol/l in a single tertiary intensive care unit in Australia. We measured quantitative bedside blood 3-beta-hydroxybutyrate (β-OHB) and semi-quantitative urine ketones on ICU admission and daily during ICU stay, for a maximum of 10 consecutive days. Results: Median blood β-OHB level on admission was 0.3 (0.1, 0.8) mmol/l. Ketoacidosis was rare (3 %), but some level of ketosis (β-OHB ≥0.6 mmol/l) was found in 38 patients (63 %) early during their ICU stay. However, there was no significant difference in prevalence or severity of ketonemia and ketonuria among patients with BGL above (permissive hyperglycemia) or below 10 mmol/l. On multivariable linear regression analysis there was no association between blood ketone levels and BGL, HbA1c, lactate levels, hematocrit, catecholamine infusion or APACHE III score. In contrast, blood ketone levels tended to be higher after cardiopulmonary bypass surgery (P = 0.06). Conclusions: Liberal glycemic control in critically ill diabetic patients does not appear to be associated with a high prevalence of ketoacidosis or ketonemia. Moreover, ketosis is typically present on admission and resolves rapidly. Finally, cardiopulmonary bypass surgery may be an important trigger of ketone body production. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12615000216516; trial registration date 5 March 2015). Keywords: Ketone bodies, 3-beta-hydroxybutyrate, Diabetes mellitus, Critical illness, Permissive hyperglycemia, Adults * Correspondence: [email protected] 1Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg 3084, VIC, Australia 5Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Luethi et al. Critical Care (2016) 20:297 Page 2 of 11 Background Methods Current guidelines recommend using insulin to main- Data collection tain a blood glucose level (BGL) between 6 and We performed a prospective observational study in all 10 mmol/l in critically ill patients [1–4]. However, diabetic patients admitted to a single tertiary adult controlling glucose within this target range is associ- ICU between 30 August and 17 November 2015. All ated with a relatively high rate of hypoglycemia [5] patients were treated in accordance with our local and increased mortality [6] in diabetic patients espe- protocol for diabetic patients targeting a blood glu- cially if adapted to chronic hyperglycemia (glycated cose levels (BGL) between 10 and 14 mmol/l and in hemoglobin A1c [HbA1c] >7 %). Therefore, a more which BGLs above 14 mmol/l were treated with intra- liberal glycemic approach (target BGL between 10 venous or subcutaneous insulin. The Austin Health and 14 mmol/l) may be safer in patients with dia- Human Research Ethics Committee approved the betes. Recent pilot studies have demonstrated that study (approval number LNR/14/Austin/487, HREC such "permissive hyperglycemia" effectively reduces 131217 and 120712) with a waiver for informed con- the need for exogenous insulin administration [7]. sent. The study was performed in accordance with Consequently, in response to the introduction of a liberal the ethical standards laid down in the 1964 Declar- glucose protocol in diabetic patients, the incidence of both ation of Helsinki and its later amendments. absolute hypoglycemia (BGL <3.9 mmol/l) and potentially For the purpose of this study, we excluded patients harmful relative hypoglycemia (an acute and marked de- admitted with diabetic ketoacidosis (DKA) or a hyper- crease in glycaemia) may be reduced. glycemic hyperosmolar state (HHS). We collected However, whether such liberal strategies lead to demographic data, ICU admission diagnoses, type of relative insulin deficiency, accelerated ketone body diabetes, insulin dependency, chronic medication and production and induce ketoacidosis is uncertain. In Acute Physiology and Chronic Health Evaluation addition to insulin deficiency, several other factors (APACHE) III score. We obtained daily data on use may stimulate ketogenesis via beta-oxidation of free of renal replacement therapy (RRT), incidence of fatty acids (FFA) in critically ill patients. Such factors acute liver failure, rate of adrenaline and noradren- include fasting (a ubiquitous state in patients admit- aline infusion, type and rate of enteral or parenteral ted to the intensive care unit [ICU]), increased secre- nutrition and insulin administration. tion of counter-regulatory hormones (glucagon, adrenaline, growth hormone and cortisol), administra- Blood and urine sample collection and analysis tion of exogenous catecholamines (adrenaline and We collected arterial blood gas (ABG) data and spot noradrenaline) [8] and administration of parenteral urine samples for measurement of blood and urine nutrition containing medium-chain triglycerides [9]. ketone levels as soon as possible after ICU admission. Furthermore, entry of acetyl coenzyme A into the Thereafter, we performed daily ketone measurement Krebs cycle may be impaired during critical illness early in the morning, which likely represents peak due to reduced oxaloacetate levels. Consequently, ketone levels [13] and simultaneously tested urine more acetyl coenzyme will be used for synthesis of samples for ketonuria until ICU discharge or up to a ketone bodies [10]. Similarly, elevated levels of de- maximum of 10 days. We measured blood β- aminated amino acids may feed ketogenesis. More- hydroxybutyrate (β-OHB) using the Freestyle Optium over, although the mechanism is less clear, alkalosis Xceed point-of-care meter (Abbott Diabetes Care Inc., appears to stimulate ketogenesis, particularly in dia- Maidenhead, UK). Simultaneously, we measured betic subjects [11]. Finally, elevated blood ketone hematocrit since previous data suggest that point-of- levels have been observed following cardiopulmonary care platforms may overestimate β-OHB at subnormal bypass surgery, especially when performed under hematocrit levels [14]. Ketonuria was semi-quantified hypothermia [12]. Although, many of these factors using Combur-test® strips (Roche Diagnostics, Rotk- may co-exist in the ICU setting, their combined im- reuz, Switzerland). ABG samples were analyzed using pact on ketone body production is unknown. the Radiometer ABL825 blood gas analyzer (Radiom- Accordingly, we conducted a prospective observational eter Medical A/S, Brønshøj, Denmark). We analysed study to explore the incidence of ketosis, ketonuria and HbA1c on ICU admission at our central laboratory, ketoacidosis during liberal glucose management of critic- using COBAS INTEGRA® 800 (Roche Diagnostics, In- ally ill diabetic patients. In addition, we aimed to assess dianapolis, IN, USA). the association of chronic glycaemia (HbA1c), acute gly- caemia, illness severity, alkalosis, catecholamine infusion Definitions and cardiopulmonary bypass surgery with blood ketone We categorized ketosis according to blood β-OHB levels levels on ICU admission in such patients. as absent (<0.6 mmol/l), mild (0.6–1.5 mmol/l), moderate Luethi et al. Critical Care (2016) 20:297 Page 3 of 11 (1.6–3 mmol/l) or marked (>3 mmol/l). Ketonuria was patients were admitted with acute liver failure and semi-quantified as mild, moderate or marked for urine ke- one with acute alcohol intoxication. Four patients had tone levels of 1–4 mmol/l, 5–14 mmol/l and ≥15 mmol/l, a history of chronic alcohol abuse. respectively. The presence of ketoacidosis was assessed A total of 46 (77 %) patients had a peak BGL using both definitions suggested by the American Diabetes ≥10 mmol/l during ICU admission. Compared to pa- Association (ADA) and the Joint British Diabetes Society tients with a peak BGL <10 mmol/l (n = 14), patients (JBDS) [15, 16]. with a peak BGL ≥10 mmol/l were younger (P = 0.02), had higher HbA1c (7.0 [6.2, 7.8] % vs. 6.2 [5.9,
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