Supplementary Material for: Ketone Management in Pediatric Diabetes Centers in the United States: Current Practices and a call for Improved Standardization

Introduction: Diabetic ketoacidosis (DKA) is the leading cause of mortality among youth with type 1 diabetes (T1D). Guidelines for DKA prevention exist, however, specific guidance about when to check ketones and how to manage youth using insulin pumps and automated insulin delivery (AID) systems is lacking.

Methods: A 35-item online survey exploring clinical ketone management practices for youth with T1D in the United States was distributed to diabetes healthcare professionals (HCPs). Survey responses, including multiple choice and Likert scale questions, were summarized and rates of agreement and disagreement (Likert scale 4,5 vs 1,2,3) are reported.

Results: In total, 123 HCPs (51% physicians, 26% diabetes educators, 19% nurse practitioners) from 47 institutions completed the survey. Seventy percent worked at academic specialty centers. Ninety-seven percent reported >50% CGM use in their clinic and 72% reported >50% insulin pump use. Although 79% reported having ketone management protocols, the level and duration of hyperglycemia at which ketone monitoring was advised ranged from >200-350 mg/dl and from 0 minutes to >6 hours of duration. While 72% had distinct ketone management protocols for pump users, only 29% had specific protocols for AID. Sixty-two percent agreed that DKA due to infusion site failure was a significant problem in their practice and 70% agreed there was a need to standardize ketone management guidelines.

Conclusions: The preventable nature and high incidence of DKA highlights the need to build consensus for clinical ketone management and to develop tools to facilitate management, especially as the use of diabetes technologies continues to increase.

引言：糖尿病酮症酸中毒（Diabetic ketoacidosis, DKA）是青少年1型糖尿病（Type 1 diabetes, T1D）患者死亡的首要致死原因。目前虽已有DKA预防相关指南，但针对何时检测酮体、如何管理使用胰岛素泵及自动胰岛素输送（Automated Insulin Delivery, AID）系统的青少年患者的具体指导仍存在缺失。

研究方法：本研究针对美国青少年1型糖尿病患者的临床酮体管理实践，设计了包含35个题项的在线调查问卷，并向糖尿病医护人员（Healthcare Professionals, HCPs）发放。研究对问卷回收结果（含选择题与李克特量表题）进行汇总分析，并报告了受访者的同意与不同意占比（以李克特量表4、5分记为同意，1、2、3分记为不同意）。

研究结果：最终共有来自47家机构的123名糖尿病医护人员完成了问卷调研，其中51%为医师、26%为糖尿病教育者、19%为执业护士。70%的受访者供职于学术专科中心。97%的受访者表示其所在门诊中持续葡萄糖监测（Continuous Glucose Monitoring, CGM）设备的使用率超过50%，72%的受访者表示门诊胰岛素泵使用率超过50%。尽管79%的受访者表示所在机构已制定酮体管理方案，但建议开展酮体监测的高血糖阈值与时长范围差异较大：高血糖阈值介于200~350 mg/dl之间，监测时长则从0分钟至超过6小时不等。虽有72%的受访者为胰岛素泵使用者制定了专属酮体管理方案，但仅29%的受访者为使用自动胰岛素输送系统的患者制定了针对性方案。62%的受访者认可“输注部位故障引发的DKA是其临床实践中的突出问题”这一观点，另有70%的受访者认同需统一标准化的酮体管理指南。

结论：DKA具有可预防性且发病率较高，这凸显了针对临床酮体管理建立共识、开发便捷化管理工具的必要性，尤其是在糖尿病相关技术应用持续普及的当下。