Practical method in the diagnosis of diabetic ketoacidosis: end-tidal carbon dioxide

Year 2024, Volume: 10 Issue: 3, 303 - 310, 04.05.2024

Ahmet Kayalı , Ejder Saylav Bora

https://doi.org/10.18621/eurj.1430099

Abstract

Objectives: Diabetic ketoacidosis (DKA) poses a life-threatening risk in uncontrolled diabetes. Current diagnostic criteria rely on invasive measures, leading to potential delays in treatment initiation. This study aimed to assess the diagnostic utility of noninvasive end-tidal carbon dioxide (EtCO2) measurements in DKA patients.

Methods: A prospective, cross-sectional study was conducted in a tertiary-level Emergency Medicine Clinic from January 2021 to January 2023. Participants included adults with DKA symptoms and those with stable vital signs as controls. EtCO2 levels were measured using a capnograph device. Diagnostic criteria for DKA were blood glucose ≥250 mg/dL, ketonuria, ketonemia, and metabolic acidosis (pH<7.3 or bicarbonate <15 mEq/dL). Statistical analysis was performed using SPSS Statistics.

Results: Of 730 participants, 120 had DKA, 410 did not, and 200 served as controls. EtCO2 levels significantly differed between DKA, non-DKA, and control groups (P<0.05). EtCO2 correlated with pH, lactate, base deficit, and bicarbonate (P<0.05). ROC analysis showed an AUC of 0.86 for EtCO2 in diagnosing DKA (P<0.01), with 91.67% sensitivity and 74.39% specificity at a cut-off value 23.7.

Conclusion: This study suggests that EtCO2 measurement is a valuable noninvasive tool for diagnosing and assessing the severity of DKA in the emergency department. An EtCO2 threshold of <23.7 could prompt consideration of DKA in patients with elevated blood glucose levels. More extensive multicenter studies are warranted to validate these findings further. EtCO2 measurement could facilitate early DKA diagnosis and improve patient outcomes.

Keywords

Diabetic ketoacidosis, end tidal CO2, fast diagnosis, emergency medicine

References

• 1. Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am. 2006;35(4):725-751, viii. doi: 10.1016/j.ecl.2006.09.006.
• 2. Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract. 2019;155:107797. doi: 10.1016/j.diabres.2019.107797.
• 3. Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019;365:l1114. doi: 10.1136/bmj.l1114.
• 4. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343. doi: 10.2337/dc09-9032.
• 5. Garcia E, Abramo TJ, Okada P, Guzman DD, Reisch JS, Wiebe RA. Capnometry for noninvasive continuous monitoring of metabolic status in pediatric diabetic ketoacidosis. Crit Care Med. 2003;31(10):2539-2543. doi: 10.1097/01.CCM.0000090008.79790.A7.
• 6. Ward KR, Yealy DM. End-tidal carbon dioxide monitoring in emergency medicine, Part 1: Basic principles. Acad Emerg Med. 1998;5(6):628-636. doi: 10.1111/j.1553-2712.1998.tb02473.x.
• 7. Long B, Koyfman A, Vivirito MA. Capnography in the Emergency Department: a review of uses, waveforms, and limitations. J Emerg Med. 2017;53(6):829-842. doi: 10.1016/j.jemermed.2017.08.026.
• 8. Karaali R, Çakır A, Bora ES, Akyol PY, Kavalcı C, Acar H. The evaluation of end tidal carbon dioxide values in intubated patients with COVID-19. Acta Biomed. 2022;93(1):e2022032. doi: 10.23750/abm.v93i1.11989.
• 9. Fearon DM, Steele DW. End-tidal carbon dioxide predicts the presence and severity of acidosis in children with diabetes. Acad Emerg Med. 2002;9(12):1373-1378. doi: 10.1111/j.1553-2712.2002.tb01605.x.
• 10. Whitaker DK. Time for capnography - everywhere. Anaesthesia. 2011;66(7):544-549. doi: 10.1111/j.1365-2044.2011.06793.x.
• 11. Kodali BS. Capnography outside the operating rooms. Anesthesiology. 2013;118(1):192-201. doi: 10.1097/ALN.0b013e318278c8b6.
• 12. Nassar BS, Schmidt GA. Capnography during critical illness. Chest. 2016;149(2):576-585. doi: 10.1378/chest.15-1369.
• 13. Manifold CA, Davids N, Villers LC, Wampler DA. Capnography for the nonintubated patient in the emergency setting. J Emerg Med. 2013;45(4):626-632. doi: 10.1016/j.jemermed.2013.05.012.
• 14. Kartal M, Eray O, Rinnert S, Goksu E, Bektas F, Eken C. ETCO₂: a predictive tool for excluding metabolic disturbances in nonintubated patients. Am J Emerg Med. 2011;29(1):65-69. doi: 10.1016/j.ajem.2009.08.001.
• 15. Agus MS, Alexander JL, Mantell PA. Continuous non-invasive end-tidal CO2 monitoring in pediatric inpatients with diabetic ketoacidosis. Pediatr Diabetes. 2006;7(4):196-200. doi: 10.1111/j.1399-5448.2006.00186.x.
• 16. Bhattaram S, Shinde VS, Khumujam PP, Anilkumar AP, Reddy DK. Capnography as a tool for triaging and diagnosis of diabetic ketoacidosis in the emergency department: a prospective observational study. Turk J Emerg Med. 2023;23(3):169-175. doi: 10.4103/tjem.tjem_15_23.
• 17. Soleimanpour H, Taghizadieh A, Niafar M, Rahmani F, Golzari SE, Esfanjani RM. Predictive value of capnography for suspected diabetic ketoacidosis in the emergency department. West J Emerg Med. 2013;14(6):590-594. doi: 10.5811/westjem.2013.4.14296.
• 18. Bou Chebl R, Madden B, Belsky J, Harmouche E, Yessayan L. Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department. BMC Emerg Med. 2016;16:7. doi: 10.1186/s12873-016-0072-7.
• 19. Taghizadieh A, Pouraghaei M, Moharamzadeh P, et al. Comparison of end-tidal carbon dioxide and arterial blood bicarbonate levels in patients with metabolic acidosis referred to emergency medicine. J Cardiovasc Thorac Res. 2016;8(3):98-101. doi: 10.15171/jcvtr.2016.21.
• 20. Gilhotra Y, Porter P. Predicting diabetic ketoacidosis in children by measuring end-tidal CO2 via non-invasive nasal capnography. J Paediatr Child Health. 2007;43(10):677-680. doi: 10.1111/j.1440-1754.2007.01186.x.
• 21. Hunter C, Putman M, Foster J, et al. Utilizing end-tidal carbon dioxide to diagnose diabetic ketoacidosis in prehospital patients with hyperglycemia. Prehosp Disaster Med. 2020;35(3):281-284. doi: 10.1017/S1049023X20000485.
• 22. Sezik S, Hakoğlu O, Okuş O, Sorgun O. Trends in Emergency Department visits, and hospital admissions pre- and during Covid 19 pandemic. Arch Curr Med Res. 2023;4(1):47-57. doi: 10.47482/acmr.1199056.