High-risk profile for perioperative diabetic ketoacidosis in patients undergoing femoral fracture surgery and prevention implications

Background/Objective Diabetic ketoacidosis (DKA) is a severe metabolic complication, but data on perioperative DKA in patients undergoing femoral fracture surgery remain limited. This study aimed to identify risk factors and associated complications of perioperative DKA in this population using the National Inpatient Sample (NIS). Methods This retrospective study analyzed NIS data from 2016–2022. Patients with traumatic femoral fracture who underwent internal fixation were identified by ICD-10-CM/PCS codes. DKA was identified by ICD-10 codes E08.1, E09.1, E10.1, E11.1, and E13.1. Multivariable models examined demographic, hospital, comorbidity, and complication associations, with FDR correction. Results Among 337,988 patients, 579 had perioperative DKA. Annual DKA proportions ranged from 0.128% to 0.219%, with an overall increasing trend (Cochran-Armitage p=0.00272). In the comorbidity-domain model, additional diabetes coding (OR=4.074, 95% CI 3.209–5.173) and fluid/electrolyte disorders (OR=3.695, 95% CI 2.982–4.580) were strongly associated with DKA and remained significant after FDR correction. DKA was also associated with sepsis, acute renal failure, shock, pressure ulcer, dialysis, intestinal obstruction, and acute myocardial infarction, as well as longer length of stay and higher hospitalization costs. Conclusions Perioperative DKA after femoral fracture surgery is uncommon but showed an increasing trend and was strongly associated with diabetes, fluid/electrolyte disorders, severe complications, and greater healthcare utilization. These findings support targeted metabolic monitoring in high-risk patients.