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Background Treatment of diabetic ketoacidosis with intravenous insulin is effective but resource intensive. Treatment guidelines recommend transitioning to subcutaneous insulin when the anion gap closes, but transition failures due to recrudescent ketoacidosis are common despite adherence to treatment protocols following such guidance. Study Objective The primary objective of our study was to evaluate the ability of serum bicarbonate levels of ≤16 mEq/L to predict intravenous to subcutaneous transition failures among those with a normal anion gap at the time of transition. Design and Setting This retrospective cohort study evaluated critically ill adult patients with a primary diagnosis of diabetic ketoacidosis. Historical patient data were obtained by manual chart review. The primary outcome was transition failure, defined as the re‐initiation of intravenous insulin within 24 h of transitioning to subcutaneous insulin. Odds ratios were calculated using generalized estimating equations with a logit link and weighted by standardized inverse probability weights to assess the predictive value of serum bicarbonate levels. Main Results The primary analysis included 93 patients with a total of 118 distinct transitions. In the adjusted analysis, patients whose anion gap had normalized but had a serum bicarbonate of ≤16 mEq/L were significantly more likely to experience a transition failure (odds ratio = 4.74, 95% confidence interval: 1.24–18.1, p = 0.02). The results of the unadjusted analysis were similar. Conclusions In patients with a normal anion gap at the time of insulin transition, serum bicarbonate levels of ≤16 mEq/L were associated with significantly increased odds of transition failure.

INTRODUCTION: Patients who suffer neurologic injury that require ventriculoperitoneal shunt(VPS) placement often also require gastrostomy procedures for feeding access and nutritional support. The timing of these procedures in relation to each other has been debated in the literature, largely steaming from a proposed risk of infection and displacement resulting in a need for revision related to the presence of a gastrostomy.METHODS: In an all-payor database, patients undergoing index gastrostomy procedures and VPS placement between 1/2010-10/2020 were identified. Patients were stratified as undergoing gastrostomy placement before, on the same day as, and following the placement of a shunt. The primary outcome of the study was rates of revision All outcomes were evaluated within 30-months following index-shunting. Patients were matched based upon logistic-regression models that evaluated the independent effects of patient and procedural factors on the primary-outcome.RESULTS: A total of 4,290-patients were identified as undergoing VPS and gastrostomy procedures. Following a 1:1:1-match procedure, 852-patient records were analyzed. Patients undergoing gastrostomy and VPS on the same day or gastrostomy procedures before VPS (Odds Ratio [OR] 0.55, 95% Confidence Interval [CI] 0.33-0.91 vs. OR 0.60, 95% CI 0.36-0.97, respectively) were observed to have significantly lower rates of revision at 30-months following index shunting when compared to those patients who underwent gastrostomy placement after VPS. No significant differences were noted in rates of infection, mechanical complications, g-tube infections, or shunt displacement between the three approaches.CONCLUSIONS: Patients undergoing shunting and gastrostomy tube placement procedures may benefit from undergoing the procedures at the same time as patients undergoing these procedures at the same time are at a decreased risk of repeat requirement for anesthesia reduced rates of VPS revision following observed in comparison to patients undergoing gastrostomy placement after VPS.

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