Association Between Initial Beta-Hydroxybutyrate Level and Process Measures of Resource Utilization in the Management of Diabetic Ketoacidosi

International guidelines on diabetic ketoacidosis (DKA) emphasize serum beta-hydroxybutyrate (BOHB) to stratify DKA severity and in-hospital level of care: mild to moderate (BOHB 3.0-6.0 mmol/L): regular or intermediate care unit; severe (>6.0 mmol/L): intensive care unit. However, these guidelines are based on expert consensus, and high-quality clinical data correlating initial BOHB with DKA duration and resource utilization is limited. We sought to quantify if initial BOHB correlates with DKA duration and measures of resource utilization to inform emergency department (ED) disposition.

This is a retrospective observational analysis of adult ED patients with DKA (BOHB ≥3 mmol/L, glucose ≥200 mg/dL, pH <7.3 and/or bicarbonate <18 mmol/L) from 2015 – 2024 at a quaternary medical center. Visits were included if a fixed-dose intravenous insulin (0.1u/kg/hr) order set was used and BOHB was measured ≤3 hours after insulin initiation. Outcomes included time to: bicarbonate >18 mmol/L, pH >7.3, and transition to subcutaneous insulin; duration of insulin infusion; hospital charges; and length of stay (LOS). Separate bivariate and multivariable logistic regression analyses tested BOHB as a predictor of outcomes. Covariates included age, gender, Charlson Comorbidity Index, race/ethnicity, weight, and diabetes type.

A total of 856 encounters from 527 unique patients were included (mean age 40.2 years; 61% female; 28% Black; 76% type I diabetes). Median initial BOHB was 8.6±3.2 mmol/L. After controlling for covariates, higher initial BOHB level was associated with longer insulin infusion duration (b [95% CI] = 1.3 [0.8–1.7], p<0.001), delayed bicarbonate (0.8 [0.6–0.9], p<0.001) and pH normalization (0.1 [0.05–0.2], p=0.001), later transition to subcutaneous insulin (0.5 [0.3–0.7], p<0.001), greater hospital charges (1,418 [55-2,780]], p=0.04), and longer LOS (0.1 days [0.01-0.3], p=0.04).

Among adult ED patients with DKA treated with standardized insulin therapy, higher initial BOHB was associated with prolonged DKA duration and increased resource utilization. Each 1-unit increase in BOHB level was associated with a 1.3-hour increase in duration of insulin infusion. Initial BOHB may serve as an early, quantitative predictor of DKA duration and inform ED disposition decisions to optimize resource utilization.