Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial

Treatment protocols for pediatric diabetic ketoacidosis (DKA) vary considerably among centers in the USA and worldwide. The optimal protocol for intravenous (IV) fluid administration is an area of particular controversy, mainly in regard to possible associations between rates of IV fluid infusion and the development of cerebral edema (CE), the most common and the most feared complication of DKA in children. Theoretical concerns about associations between osmotic fluid shifts and CE have prompted recommendations for conservative fluid infusion during DKA. However, recent data suggest that cerebral hypoperfusion may play a role in cerebral injury associated with DKA. Currently, there are no existing data from prospective clinical trials to determine the optimal fluid treatment protocol for pediatric DKA. The Pediatric Emergency Care Applied Research Network FLUID (FLuid therapies Under Investigation in DKA) study is the first prospective randomized trial to evaluate fluid regimens for pediatric DKA. This 13-center nationwide factorial design study will evaluate the effects of rehydration rate and fluid sodium content on neurological status during DKA treatment, the frequency of clinically overt CE and long-term neurocognitive outcomes following DKA.

Variation in resource use and readmission for diabetic ketoacidosis in children's hospitals

OBJECTIVE

We sought to characterize variation in hospital resource utilization and readmission for diabetic ketoacidosis (DKA) across US children's hospitals.

METHODS

The study sample included a retrospective cohort of children aged 2 to 18 years with a diagnosis of DKA at 38 children's hospitals between 2004 and 2009. The main outcomes were resource utilization as determined by total standardized cost per hospitalization, overall and non-ICU length of stay (LOS), and readmission for DKA within 30 and 365 days.

RESULTS

There were 24,890 DKA admissions, and 20.3% of these were readmissions within 1 year. The mean hospital-level total standardized cost was $7142 (range $4125-$11,916). The mean hospital-level LOS was 2.5 days (1.5-3.7), and the non-ICU portion was 1.9 days (0.7-2.7). The mean hospital-level readmission within 365 days was 18.7% (6.5%-41.1%) and within 30 days was 2.5% (0.0%-7.1%). Hospital bed days overall, and in particular the non-ICU portion, accounted for the majority of the total standardized cost per hospitalization (overall 57%; non-ICU 36%) and explained most of the variation in resource use. Even after adjusting for difference in patient characteristics across hospitals, widespread differences existed across hospitals in total standardized cost, LOS, and readmission rates (P < .001).

CONCLUSIONS

Readmission for DKA within a year of hospitalization is common. US children's hospitals vary widely in resource use, hospital LOS, and readmission rates for patients with DKA. Our study highlights the need for additional research to understand these differences and to identify the most cost-effective strategies for managing diabetes across the continuum of care.

Factitious disorder as repeated diabetic ketoacidosis: a case report

Factitious disorder is a challenging entity, both in diagnosis and treatment. The clinical presentation is variable in feigned symptoms and spans virtually all organ systems. The diagnostic criteria are simple, yet making the diagnosis is often complicated and can be delayed by focusing on the urgent or readily observable diagnosis. In this article, the authors present a case of factitious diabetic ketoacidosis resulting from the deliberate withholding of exogenous insulin. This particular case is dissected in order to portray the underlying psychopathology. In doing so, the authors illustrate how a patient with factitious disorder might fulfill unmet, presumably unrealized needs. The authors also discuss the diagnostic criteria and treatment strategies of factitious disorder, both of which are of considerable debate within the psychiatric community.

Pancreatitis and diabetic ketoacidosis with quetiapine use

There have been case reports about second-generation antipsychotics causing pancreatitis. In addition, there has been a case report of pancreatitis without diabetic ketoacidosis associated with the use of quetiapine, specifically, and a case report of a patient receiving quetiapine who rapidly developed hyperglycemia and acidosis without evidence of acute or chronic pancreatitis. We present what we believe to be the first report of a patient who developed pancreatitis and life-threatening diabetic ketoacidosis while receiving quetiapine.

Recent advances in childhood diabetes mellitus

Diabetes mellitus (DM) is a syndrome characterized by disturbed metabolism of carbohydrate, protein, and fat. It is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin. It presents with very different medical and psychosocial issues in children.

Epidemiological studies indicate that there is gradual but steady increase in the incidence of both type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in both developed and developing countries. The manifestations, therapy goals, clinical course, susceptibility to complications of diabetes differ among childhood cases.

T1DM accounts for the majority of cases of diabetes in children. Diabetic ketoacidosis may be the initial presentation of T1DM in many children particularly in Africa probably due to low level of awareness.

The focus of this review on T1DM is to provide an overview of the major advances in the aetiology, pathogenesis, and clinical management of newly diagnosed children and their subsequent management with the aim of ensuring optimal growth and development as well as preventing acute and chronic complications. The advances in insulin therapy and regimens and the presentation and management of diabetic ketoacidosis are discussed. The prospects for the cure of the disease are also highlighted in this review.