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Li GH, Huang K, Dong GP, Zhang JW, Gong CX, Luo FH, Luo XP, Wang CL, Zhu M, Li P, Wang L, Fu JF. Clinical Incidence and Characteristics of Newly Diagnosed Type 1 Diabetes in Chinese Children and Adolescents: A Nationwide Registry Study of 34 Medical Centers. Front Pediatr 2022; 10:888370. [PMID: 35783304 PMCID: PMC9242427 DOI: 10.3389/fped.2022.888370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the clinical incidence and characteristics of type 1 diabetes mellitus (T1DM) of children and adolescents at the time of initial diagnosis in China. Methods Data on all pediatric patients with newly diagnosed T1DM were retrospectively collected from 34 medical centers in 25 major cities in China from January 2015 to January 2020. Patients were classified into three age groups: <5 years, 5 to <10 years, and ≥10 years of age. The same patient population was also categorized into diabetic ketoacidosis (DKA) and non-DKA groups based on clinical criteria. Results The mean annual clinical incidence of T1DM was 3.16/100,000 from the years 2015 to 2019. A total of 6,544 patients with newly diagnosed T1DM aged 0-16 years (median 7.84 ± 3.8) were studied [ages <5 years (29.3%), 5 to <10 years (38.7%), and ≥10 years (32%)], 52.4% of them were women. In total, 90.5% of the cases were occurred in individuals without a family history. Patients had lower C-peptide (CP) and body mass index (BMI) z scores when compared with healthy children, 41.8% of them had measurable T1DM-related antibodies and 52.7% had DKA. Among all three age groups, the <5 years group had the lowest BMI z score, CP, and glycated hemoglobin (HbA1c) on average, while it had the highest incidence rate of DKA (56.9%). Compared to the non-DKA group, the DKA group was significantly younger, with a lower BMI z score and CP, higher antibody positive rate, HbA1c, and the rate of insulin pump therapy. Conclusion The clinical incidence of T1DM in children and adolescents in China was 3.16/100,000. Patients with DKA at the first diagnosis of T1DM have a worse β-cell function. Public health measures for the prevention and treatment of T1DM should focus on preschoolers (aged <5 years) in particular, considering the severity and the highest frequency of DKA in this age group. More efforts should be dedicated to early screening and diagnosis of the T1DM.
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Affiliation(s)
- Guo-Hua Li
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ke Huang
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guan-Ping Dong
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jian-Wei Zhang
- Department of Pediatrics, Shaoxing Maternal and Child Health Care Hospital, Hangzhou, China
| | - Chun-Xiu Gong
- Endocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children's Hospital, Beijing, China
| | - Fei-Hong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Ping Luo
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Lin Wang
- Department of Pediatric, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhu
- Department of Endocrinology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children's Hospital of Shanghai Jiao Tong University, Shanghai, China
| | - Ling Wang
- Laboratory for Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Jun-Fen Fu
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Saikia D, Mittal M, Kanakaraju C, Dhingra D, Kumar M. Efficacy and Safety of Low Dose Insulin Infusion against Standard Dose Insulin Infusion in Children with Diabetic Ketoacidosis- An Open Labelled Randomized Controlled Trial. Indian J Endocrinol Metab 2022; 26:173-179. [PMID: 35873943 PMCID: PMC9302420 DOI: 10.4103/ijem.ijem_50_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/12/2022] [Accepted: 03/30/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of low dose insulin infusion (0.05 U/kg/h) against the standard dose insulin infusion (0.1 U/kg/h) in children with diabetic ketoacidosis. METHOD Children (age <12 years, n = 30) presenting with diabetic ketoacidosis were enrolled and randomised to receive insulin infusion either as 0.05 U/kg/h (low dose) or 0.1 U/kg/h (standard dose) as an open labelled randomised controlled trial. The rest of the management was identical in both groups. The time taken for resolution of acidosis (pH ≥7.3 and HCO3 ≥15) was the primary outcome variable. The secondary outcome variables included the time taken until a decline in blood glucose to 250 mg/dl, the proportion of children developing hypoglycemia and hypokalemia, and any treatment failure. RESULTS The two groups were similar with respect to mean age, weight and gender distribution. New-onset diabetes was diagnosed on 24/30. The mean ± SD time for resolution of acidosis was similar between the groups; 27.0 ± 6.1 hours in the low dose group vs 23.4 ± 7.3 hours in standard dose group, P = 0.16. The mean time for the decline in blood glucose to 250 mg/dl was 13.0 ± 5.9 hours in low dose vs 11.6 ± 6.0 hours in standard dose group, P = 0.52. A lesser proportion of participants developed hypoglycemia and hypokalemia in the low dose group, though not statistically significant. There was no incidence of treatment failure in either group. CONCLUSION Low dose insulin infusion is equally effective and safe as standard dose insulin infusion in children with diabetic ketoacidosis.
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Affiliation(s)
- Diganta Saikia
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Medha Mittal
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | | | - Dhulika Dhingra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
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Badawy MK, Viswanath V, Khetriwal B, Pradhan S, Williams RM, Pathan N, Marcovecchio ML. Diabetic ketoacidosis with severe hypokalemia and persistent hypernatremia in an adolescent girl with COVID‐19 infection. Clin Case Rep 2022; 10:e05406. [PMID: 35145691 PMCID: PMC8818290 DOI: 10.1002/ccr3.5406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 11/30/2022] Open
Abstract
We report a case of new‐onset type 1 diabetes in a girl presenting with severe diabetic ketoacidosis, complicated by profound hypokalemia and hypernatremia. We describe the clinical course, management challenges, and the potential role of the concomitant COVID‐19 infection in the complexity of this case.
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Affiliation(s)
- Mohammed Kamal Badawy
- Paediatric Intensive Care Unit Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Vidya Viswanath
- Paediatric Endocrinology and Diabetes Department Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | | | | | - Rachel M. Williams
- Paediatric Endocrinology and Diabetes Department Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Nazima Pathan
- Paediatric Intensive Care Unit Cambridge University Hospitals NHS Foundation Trust Cambridge UK
- Department of Paediatrics University of Cambridge Cambridge UK
| | - Maria Loredana Marcovecchio
- Paediatric Endocrinology and Diabetes Department Cambridge University Hospitals NHS Foundation Trust Cambridge UK
- Department of Paediatrics University of Cambridge Cambridge UK
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Baloch SH, Ibrahim PMN, Lohano PD, Gowa MA, Mahar S, Memon R. Pediatric Risk of Mortality III Score in Predicting Mortality Among Diabetic Ketoacidosis Patients in a Pediatric Intensive Care Unit. Cureus 2021; 13:e19734. [PMID: 34938616 PMCID: PMC8684832 DOI: 10.7759/cureus.19734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 01/09/2023] Open
Abstract
Background Diabetic ketoacidosis (DKA) is one of the most common complications of type 1 diabetes. Mortality is not uncommon in DKA, mostly in younger children with severe DKA and those complicated with cerebral edema. Early identification of high-risk patients can help in timely interventions to improve the outcome of DKA. Pediatric Risk of Mortality (PRISM III) is a standard scoring system to objectively predict the prognosis and outcome of pediatric intensive care unit (PICU) patients. Objective To predict the need for inotrope and mechanical ventilation and mortality rate using PRISM III in DKA patients admitted to PICU. Methods A prospective observational study was conducted in the PICU of the National Institute of Child Health, Karachi, from February 2020 to September 2021 involving 114 children. PRISM III scoring protocol was applied. A PRISM III score of >8 predicted higher mortality risk. Results The mean PRISM III score was 6.56 ± 3.18 with 30 (26.3%) children having a score >8. Of the 30 (26.31%) patients with >8 PRISM III scores, 14 (46.67%) needed inotropic support, 6 (20%) needed mechanical ventilation, and there were eight (26.67%) mortalities. There was no reported mortality among patients with a PRISM III score ≤8. All differences were statistically significant (p < .05). Conclusion PRISM III is a highly sophisticated scoring system that can aid clinicians in the early prediction of adverse clinical outcomes in patients with DKA. Robust scientific evidence supporting its clinical application can help practically improve the outcome of DKA in young patients.
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Affiliation(s)
- Sadam H Baloch
- Paediatrics and Endocrinology, National Institute of Child Health Karachi, Karachi, PAK
| | | | - Pooja D Lohano
- Paediatrics and Endocrinology, National Institute of Child Health Karachi, Karachi, PAK
| | - Murtaza A Gowa
- Paediatric Critical Care, National Institute of Child Health Karachi, Karachi, PAK
| | - Shazia Mahar
- Paediatrics and Endocrinology, National Institute of Child Health Karachi, Karachi, PAK
| | - Roshia Memon
- Paediatrics and Endocrinology, National Institute of Child Health Karachi, Karachi, PAK
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Rameshkumar R, Satheesh P, Jain P, Anbazhagan J, Abraham S, Subramani S, Parameswaran N, Mahadevan S. Low-Dose (0.05 Unit/kg/hour) vs Standard-Dose (0.1 Unit/kg/hour) Insulin in the Management of Pediatric Diabetic Ketoacidosis: A Randomized Double-Blind Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2255-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Hou L, Li X, Liu L, Wei H, Xiong F, Du H, Yang Y, Zhang H, Zhang Q, Yao H, Fu J, Yan X, Cui L, Liu G, Li T, Chen S, Li P, Xin Y, Liang X, Yu B, Dong Z, Chen R, Ma H, Cheng X, Luo F, Gong C, Song W, Chen X, Zhang Z, Peng X, Li G, Liang L, Maimaiti M, Cheung PT, Luo X. A Multicenter Survey of Type I Diabetes Mellitus in Chinese Children. Front Endocrinol (Lausanne) 2021; 12:583114. [PMID: 34211433 PMCID: PMC8239384 DOI: 10.3389/fendo.2021.583114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 05/17/2021] [Indexed: 01/17/2023] Open
Abstract
Purpose To investigate the features and treatment status of children with type 1 diabetes mellitus (T1DM) in China. Methods We recruited patients <14 years of age with T1DM from 33 medical centers in 25 major cities of China between January 2012 and March 2015. All patients completed a questionnaire that was conducted by their pediatric endocrinologists at all centers. Results A total of 1,603 children (755 males and 848 females) with T1DM participated in this survey. Of these, 834 (52.03%) of the patients exhibited diabetic ketoacidosis (DKA) at onset, while 769 patients (47.97%) did not exhibit DKA (non-DKA) at onset. There was a higher proportion of females (55.71%) in the cohort of patients exhibiting DKA at onset than in the non-DKA cohort (49.33%). The mean age of patients exhibiting DKA at presentation was 7.12 ± 0.14 years; this was significantly younger than that in non-DKA group (7.79 ± 0.15 years; P < 0.005). The frequency of DKA in 3 years old, 3-7 years old, and 7 years old or more was 77.21%, 26.17%, and 37.62%, respectively. Upon initial diagnosis, 29.4%, 15.2% and 11.8% of patients showed positivity for glutamic acid decarboxylase antibody (GADA), Insulin autoantibodies (IAA), or islet cell antibody (ICA), respectively. During six months follow-up, 244 patients (15.21%) reported receiving insulin pump therapy, and more than 60% of patients monitored their blood glucose levels less than 35 times per week. Although the majority of patients had no problems with obtaining insulin, 4.74% of the children surveyed were not able to receive insulin due to financial reasons, a shortage of insulin preparations, or the failure of the parents or guardians to acquire the appropriate medicine. Conclusion DKA is more common in very young children. Treatment and follow-up of T1DM in China still face very serious challenges.
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Affiliation(s)
- Ling Hou
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiuzhen Li
- Department of Genetics and Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Liu
- Department of Genetics and Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hanyang Wei
- Department of Endocrinology and Genetic, Henan Provincial Children’s Hospital, Zhengzhou, China
| | - Feng Xiong
- Department of Endocrine and Genetic Metabolism Disease, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Hongwei Du
- Department of Pediatrics, The First Affiliated Hospital, Jilin University, Changchun, China
| | - Yu Yang
- Department of Endocrinology, Metabolism, and Genetics, Children’s Hospital of Nanchang University & Jiangxi Provincial Children’s Hospital, Nanchang, China
| | - Huifeng Zhang
- Department of Pediatrics, The Second Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qin Zhang
- Department of Endocrinology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Hui Yao
- Department of Endocrinology, Wuhan Children’s Hospital, Wuhan, China
| | - Junfen Fu
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoli Yan
- Department of Pediatrics Endocrinology, Xi’an Children’s Hospital, Xi’an, China
| | - Lanwei Cui
- Department of Pediatrics, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Geli Liu
- Department of Pediatrics, General Hospital of Tianjin Medical University, Tianjin, China
| | - Tang Li
- Department of Pediatrics, Qingdao Women and Children’s Hospital, Qingdao University, Qingdao, China
| | - Shaoke Chen
- Department of Pediatrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Xin
- Department of Pediatrics Endocrinology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiangrong Liang
- Department of Endocrinology, Qilu Children’s Hospital, Shandong University, Jinan, China
| | - Baosheng Yu
- Department of Pediatrics, The Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zhiya Dong
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ruimin Chen
- Department of Endocrinology, Fuzhou Children’s Hospital, Fuzhou, China
| | - Huamei Ma
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xinran Cheng
- Department of Endocrinology and Metabolism, Chengdu Women’s and Children’s Central Hospital, Chengdu, China
| | - Feihong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Chunxiu Gong
- Endocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children’s Hospital, Beijing, China
| | - Wenhui Song
- Department of Pediatric Endocrinology, Shanxi Provincial Children’s Hospital, Taiyuan, China
| | - Xiaobo Chen
- Department of Endocrinology, Children’s Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Zhixin Zhang
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Xiangyun Peng
- Department of Endocrinology, Hunan Provincial Children’s Hospital, Changsha, China
| | - Guimei Li
- Department of Pediatrics, Shandong Provincial Hospital, Jinan, China
| | - Liyang Liang
- Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mireguli Maimaiti
- Department of Pediatrics, The First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Pik To Cheung
- Paediatric Endocrinology, Genetics, and Metabolism, Virtus Medical Group and The University of Hong Kong, Hong Kong SAR, China
| | - Xiaoping Luo
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Giri PP, Akhtar S, Laha S, Sinha R. Are we ignoring coexisting rhabdomyolysis as an important aggravating factor for acute kidney injury among childhood diabetic ketoacidosis? J Pediatr Endocrinol Metab 2021; 34:251-254. [PMID: 33027053 DOI: 10.1515/jpem-2020-0251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/28/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Although Acute Kidney Injury (AKI) has been described among childhood diabetes ketocidosis (cDKA) there is scarcity of literature on the role of concomitant rhabdomyolysis. METHOD A retrospective chart review was undertaken (2014-2018) to identify cDKA who developed AKI and had evidence of rhabdomyolysis defined by serum creatine phosphokinase (CPK) > 5 times upper limit of normal. RESULT 46 cDKA were identified. Ten (22%) developed AKI with 6/10 reaching peak AKI Stage 3 and 8/10 had co-current rhabdomyolysis. In comparison to non rhabdomyolysis group, cDKA with rhabdomyolysis were at presentation significantly more likely to be hypotensive and have higher corrected sodium and calculated osmolality. Subsequently they were more likely to develop lower trough potassium levels during treatment. Five patients, all with rhabdomyolysis, needed dialysis: median duration 9 days (range 4-35). Three children in our cohort died, all from infection complications during treatment, one in AKI only group who did not receive dialysis and two in AKI with rhabdomyolysis on dialysis. CONCLUSION Rhabdomyolysis was common among our cohort of cDKA with AKI and was associated with high morbidity and mortality. Rapid flux in electrolytes and osmolality may be important precipitating factors. We recommend larger prospective studies exploring the importance of rhabdomyolysis among cDKA with AKI.
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Affiliation(s)
- Prabhas P Giri
- Paediatric Intensive Care, Consultant, PICU, Institute of Child Health, Kolkata, India
| | - Shakil Akhtar
- Paediatric Intensive Care, Consultant, PICU, Institute of Child Health, Kolkata, India
| | - Somrita Laha
- Paediatric Intensive Care, Consultant, PICU, Institute of Child Health, Kolkata, India
| | - Rajiv Sinha
- Division of Paediatric Nephrology, Institute of Child Health, Kolkata, India
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Rohilla L, Kumar R, Walia P, Yadav J, Dayal D. "Puddles on the Road": Hurdles in the Pathway from Symptoms to Diagnosis and Treatment in Children with Type 1 Diabetes. Indian J Endocrinol Metab 2021; 25:23-30. [PMID: 34386390 PMCID: PMC8323632 DOI: 10.4103/ijem.ijem_519_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/09/2020] [Accepted: 12/19/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION This study was conducted to investigate the pathway from first symptoms to initiation of insulin regimen in children with new-onset Type 1 Diabetes Mellitus (T1DM) and explore the reasons behind diabetes ketoacidosis (DKA) at onset among children with T1DM. MATERIALS AND METHODS An exploratory study was conducted using a pretested questionnaire, among parents of children diagnosed with T1DM within preceding 3 months. RESULTS Out of the total 105 children, 56.1% were males. The median age was 7 years. The commonest reported symptoms were polydipsia (97.8%), polyuria (75.2%), and nocturia (75.2%). The mean time taken by parents from onset of symptoms to decide to visit the physician (appraisal gap) was 7.85 ± 7.95 days. The help-seeking gap (from decision-making to visiting a physician) was 3.01 ± 8.31 days, diagnostic gap (from first visit to diagnosis) was 4.19 ± 6.72 days, and the treatment gap (from diagnosis to the start of insulin) was 2.12 ± 6.87 days. The DKA at onset (was present in 39 out of 105 children 37.1%) and was higher among children with lower per-capita income (P-0.017), lack of previous experience among parents (P-0.017), longer appraisal (P-0.023), and treatment gap (P-0.009). CONCLUSION Increasing awareness about the diabetes among children among the public and primary healthcare workers can help prevent DKA at onset.
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Affiliation(s)
- Latika Rohilla
- Endocrinology and Diabetes Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar
- Endocrinology and Diabetes Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Priyanka Walia
- Endocrinology and Diabetes Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jaivinder Yadav
- Endocrinology and Diabetes Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Devi Dayal
- Endocrinology and Diabetes Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Kangin M, Talay MN, Tanriverdi Yilmaz S, Unal E, Demiral M, Asena M, Ozbek MN. A Retrospective Analysis of Children and Adolescents With Diabetic Ketoacidosis in the Intensive Care Unıt: Is It Significant that the Blood Ketone Level Becomes Negative in Diabetic Ketoacidosis? Cureus 2020; 12:e10844. [PMID: 33178500 PMCID: PMC7651777 DOI: 10.7759/cureus.10844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction: Diabetic ketoacidosis (DKA) is the most common cause of acute morbidity and mortality in children and adolescents with type 1 diabetes mellitus (T1DM). Because DKA management is associated with complications, endocrine communities have published guidelines and attempted to set standards for DKA diagnosis and management worldwide. In this study, for the patients followed up in the intensive care unit who have been treated according to DKA protocols, clinical and laboratory characteristics, differences between new and old diagnosed patients, and results of treatment were evaluated. Methods: The records of 67 patients hospitalized in the pediatric intensive care unit for the past two years were reviewed retrospectively. Patients were grouped as newly diagnosed and old diagnosed diabetics. Results: The mean age of the patients was 8.66 ± 5.0 years (3 months to 17.9 years) and 39 (58.2%) were male. Forty-five patients (67.1%) presented with mild DKA and 22 (33.9%) with severe DKA. Fourteen (63.6%) of the severe DKA cases were newly diagnosed with T1DM. Six patients had hyponatremia (corrected serum Na level <135 mmol/L) and five had hypernatremia (serum Na level >145 mmol/L). Only one of the hyponatremic patients had severe acidosis, while four of the hypernatremic patients had severe acidosis. At the 14th hour, blood glucose levels were below 200 mg/dl, blood ketones became negative in 5.8 hours, and at 9.1 hours, blood pH and/or HCO3 levels were normalized, recovery criteria were completed, and subcutaneous (SC) insulin injection was started. Of the patients, 38 (56.7) were newly diagnosed with T1DM. The mean age of newly diagnosed T1DM patients was smaller (7.40 ± 4.96) than those with old diagnosis, respiratory rates (RRs) were higher and pCO2 levels were lower on admission. Blood glucose, blood ketone negativity, acidosis, and Glasgow coma score (GCS) scores of the newly diagnosed T1DM patients improved later than the previous diagnoses. Only one patient under two years of age with a pH of 6.89 was given HCO3. None of the patients had symptomatic brain edema and death. Conclusions: As a result, DKA is an acute and serious complication of diabetes, whose results are promising when managed only with minimal individual changes according to guidelines. Bicarbonate administration is not needed except in patients with very severe acidosis. Bedside blood ketone monitoring seems to be important because it allows for early enteral feeding.
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Affiliation(s)
- Murat Kangin
- Pediatric Intensive Care, Saglik Bilimleri University, Gazi Yasargil Training and Research Hospital, Diyarbakir, TUR
| | - Mehmet Nur Talay
- Pediatric Intensive Care, Saglik Bilimleri University, Gazi Yasargil Training and Research Hospital, Diyarbakir, TUR
| | - Sibel Tanriverdi Yilmaz
- Pediatric Intensive Care, Saglik Bilimleri University, Gazi Yasargil Training and Research Hospital, Diyarbakir, TUR
| | - Edip Unal
- Pediatric Endocrinology, Saglik Bilimleri University, Gazi Yasargil Training and Research Hospital, Diyarbakir, TUR
| | - Meliha Demiral
- Pediatric Endocrinology, Saglik Bilimleri University, Gazi Yasargil Training and Research Hospital, Diyarbakir, TUR
| | - Muhammed Asena
- Pediatrics, Saglik Bilimleri University, Gazi Yasargil Training and Research Hospital, Diyarbakir, TUR
| | - Mehmet Nuri Ozbek
- Pediatric Endocrinology, Saglik Bilimleri University, Gazi Yasargil Training and Research Hospital, Diyarbakir, TUR
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Ing TS, Ganta K, Bhave G, Lew SQ, Agaba EI, Argyropoulos C, Tzamaloukas AH. The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications. Front Med (Lausanne) 2020; 7:477. [PMID: 32984372 PMCID: PMC7479837 DOI: 10.3389/fmed.2020.00477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Abstract
In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.
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Affiliation(s)
- Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, United States
| | - Kavitha Ganta
- Medicine Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Gautam Bhave
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susie Q Lew
- Department of Medicine, George Washington University School of Medicine, Washington, DC, United States
| | | | - Christos Argyropoulos
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
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Agarwal N, Dave C, Patel R, Shukla R, Kapoor R, Bajpai A. Factors Associated With Cerebral Edema at Admission in Indian Children with Diabetic Ketoacidosis. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1781-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gupta A, El-Wiher N. Therapeutic Challenges in Management of Severe Acidosis and Profound Hypokalemia in Pediatric Diabetic Ketoacidosis. Glob Pediatr Health 2019; 6:2333794X19840364. [PMID: 31001573 PMCID: PMC6454640 DOI: 10.1177/2333794x19840364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/20/2019] [Accepted: 03/06/2019] [Indexed: 11/17/2022] Open
Abstract
Profound hypokalemia in the presence of diabetic ketoacidosis (DKA) is life-threatening condition predisposing patients to cardiac arrhythmias and potentially death. Rarely do patients present with profound hypokalemia (serum K+ level <2.5 mEq/L). Pediatric patients who present to the hospital with new-onset DKA with no past medical history and have profound severe hypokalemia and acidosis can be very difficult to manage. Given insulin to these patients immediately can lead to further decrease in extracellular potassium level and lead to cardiac dysrhythmias and death. We present the case of a 14-year-old female with new-onset DKA with pH of 6.66, and potassium of 1.6 mEq/L. We started her on careful potassium replacement before starting her on insulin. She had a great prognosis without any complications. Our case presents the lowest level of pH ever reported in a survived pediatric DKA patient. We emphasize the importance of careful management of hypokalemia in patients with severe depletion. Potassium therapy with careful fluid management must be initiated prior to insulin therapy to prevent cardiac completions from hypokalemia.
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Jawaid A, Sohaila A, Mohammad N, Rabbani U. Frequency, clinical characteristics, biochemical findings and outcomes of DKA at the onset of type-1 DM in young children and adolescents living in a developing country - an experience from a pediatric emergency department. J Pediatr Endocrinol Metab 2019; 32:115-119. [PMID: 30699071 DOI: 10.1515/jpem-2018-0324] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 12/05/2018] [Indexed: 11/15/2022]
Abstract
Background As per the International Society for Pediatrics and Adolescent Diabetes (ISPAD) census, diabetic ketoacidosis (DKA) is the most frequent cause of diabetes-related death. In developing countries, DKA-related mortality rate ranges from 6% to 24% (Onyiriuka AN, Ifebi E. Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics. J Diabetes Metab Disord 2013;12:47) in contrast to 0.15%-0.31% in the Western world (Poovazhagi V. Risk factors for mortality in children with diabetic ketoacidosis from developing countries. World J Diabetes 2014;5:932-93.). In developing countries like Pakistan, the situation is more perplexing owing to uncertain or under-reported statistics about the spectrum of the disease and its prevalence, coupled with limited access to medical care and experts as well as less awareness. These limitations restrict our ability to develop interventions that are patient-centered. Our main objective was to determine the severity, clinical features, bio-chemical findings and outcomes of DKA in children aged 1 month to 16 years. Subjects and methods This retrospective study included the analysis of medical and laboratory records from patients' medical charts and the electronic database of all children aged 1 month to 16 years with newly diagnosed type-1 diabetes mellitus (T1DM) complicated with ketoacidosis, who presented to the emergency department (ED) at the Aga Khan University Hospital (AKUH), between January 2009 and December 2014. Results Diabetes mellitus complicated with DKA was the predominant diagnosis (n=113 [75.83%]) among endocrine diseases in children visiting the ED. Our study witnessed an increase in the incidence of DKA particularly after 5 years of age, with more severity in females. In our study, the mortality rate was 3.4%. Conclusions Considering the high incidence and mortality rate, it is emphasized that DKA should be considered in differential diagnosis. An awareness campaign for both general pediatricians and physicians as well as for the public is needed for better outcomes.
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Affiliation(s)
- Amna Jawaid
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Arjumand Sohaila
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Nadia Mohammad
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Unaib Rabbani
- Saudi Board Family Medicine, Ministry of Health, Qassim, Saudi Arabia
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Joseph N, Sharma S, Modi V, Manjunatha S, Siddiqui SA, Sinha M. Early Occurrence Cases of Diabetes Mellitus: Clinical Picture in Two Major Tertiary Care Hospitals in India. Curr Diabetes Rev 2019; 15:141-148. [PMID: 29692258 DOI: 10.2174/1573399814666180424123255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/05/2018] [Accepted: 04/13/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Type 1 diabetes mellitus (T1D) is one of the most common endocrine diseases in childhood. However, very limited information is available on this disease. OBJECTIVES This study was done to assess risk factors, clinical features and management practices in T1D patients. METHODS A review of records of 39 T1D cases admitted over the past five years in two hospitals was done. RESULTS The mean age at diagnosis among males (n=21) was 19.9±10.3 years and among females (n=18) was 12.3±7.5 years (t=2.614, p=0.013). Mean age at diagnosis of patients who were underweight (n=7) was 9.9±4.4 years, compared to 17.8±10.1 years among patients (n=32) with normal or overweight status (t=2.028, p=0.05). The family history of T1D was present among 7(18.0%) cases. The most common symptoms among the cases were fatigue 22(56.4%), polyuria 19(48.7%) and polydipsia 18(46.1%). The most common sign was weight loss 27(69.2%). The most common complications were diabetic nephropathy and skin infections seen each among 10(25.6%) cases. Mean duration of T1D was significantly more among patients with diabetic nephropathy (p<0.001), compared to those without. Mean HbA1c value among patients was 12.9±2.7. It was significantly more among patients with Diabetic Ketoacidosis (DKA) (p=0.012). A short-acting insulin was used in the management of T1D among 59.5% cases. The outcome of the management showed a loss of one patient who developed DKA. CONCLUSION Routine growth monitoring and blood glucose analysis is required among T1D cases. The present study provides a database of risk factors, clinical features, and management practices among patients with T1D in this region and addresses several issues important to both patients and their care providers.
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Affiliation(s)
- Nitin Joseph
- Department of Community Medicine, Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India
| | - Shreya Sharma
- Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India
| | - Vinisha Modi
- Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India
| | - Sanath Manjunatha
- Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India
| | - Saad A Siddiqui
- Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India
| | - Mihika Sinha
- Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India
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CLINICAL PROFILE OF CHILDREN WITH DIABETIC KETOACIDOSIS AND RELATED CEREBRAL EDEMA IN A TERTIARY CARE HOSPITAL FROM SOUTHERN KERALA. ACTA ACUST UNITED AC 2018. [DOI: 10.32677/ijch.2018.v05.i02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Filippatos T, Tzavella E, Rizos C, Elisaf M, Liamis G. Acid-base and electrolyte disorders associated with the use of antidiabetic drugs. Expert Opin Drug Saf 2017; 16:1121-1132. [DOI: 10.1080/14740338.2017.1361400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Theodosios Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Eleftheria Tzavella
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Christos Rizos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Diabetic Ketoacidosis: Demographic Data, Clinical Profile and Outcome in a Tertiary Care Hospital. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.7649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lopes CLS, Pinheiro PP, Barberena LS, Eckert GU. Diabetic ketoacidosis in a pediatric intensive care unit. J Pediatr (Rio J) 2017; 93:179-184. [PMID: 27770618 DOI: 10.1016/j.jped.2016.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/20/2016] [Accepted: 05/20/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To describe the characteristics of children aged 0-14 years diagnosed with diabetic ketoacidosis and compare the following outcomes between children with prior diagnosis of type 1 diabetes mellitus and children without prior diagnosis of type 1 diabetes mellitus length of hospital stay, severity on admission, insulin dosage, time of continuous insulin use, volume of fluids infused during treatment, and complications. METHODS A retrospective descriptive study with review of medical records of patients admitted to the pediatric intensive care unit of a referral hospital from June 2013 to July 2015. The following data regarding 52 admissions were analyzed: age, sex, weight, body surface area, signs, symptoms and severity on admission, blood gas, blood glucose, glycated hemoglobin, serum osmolarity, and index of mortality. The insulin dosage, time of continuous insulin use, volume administered in the expansion phase and in the first 24h, length of stay, and complications such as electrolyte disturbances, hypoglycemia, cerebral edema, and death were compared between the two groups. RESULTS Patients without a previous diagnosis of DM1 were younger at admission, with mean age of 8.4 years (p<0.01), reported more nausea or vomiting, polydipsia and polyuria, and showed more weight loss (p<0.01). This study also observed a higher prevalence of hypokalemia (p<0.01) and longer hospital stay in this group. CONCLUSIONS No differences in severity between groups were observed. The study showed that children without prior diagnosis of type 1 diabetes mellitus were younger at admission, had more hypokalemia during the course of treatment, and had greater length of hospital stay.
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Affiliation(s)
- Clarice L S Lopes
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil.
| | - Paula Pitta Pinheiro
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Luzia S Barberena
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Guilherme U Eckert
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
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Lopes CL, Pinheiro PP, Barberena LS, Eckert GU. Diabetic ketoacidosis in a pediatric intensive care unit. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2016.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Davis SM, Maddux AB, Alonso GT, Okada CR, Mourani PM, Maahs DM. Profound hypokalemia associated with severe diabetic ketoacidosis. Pediatr Diabetes 2016; 17:61-5. [PMID: 25430801 PMCID: PMC4896141 DOI: 10.1111/pedi.12246] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/29/2014] [Accepted: 10/30/2014] [Indexed: 02/06/2023] Open
Abstract
Hypokalemia is common during the treatment of diabetic ketoacidosis (DKA); however, severe hypokalemia at presentation prior to insulin treatment is exceedingly uncommon. A previously healthy 8-yr-old female presented with new onset type 1 diabetes mellitus, severe DKA (pH = 6.98), and profound hypokalemia (serum K = 1.3 mmol/L) accompanied by cardiac dysrhythmia. Insulin therapy was delayed for 9 h to allow replenishment of potassium to safe serum levels. Meticulous intensive care management resulted in complete recovery. This case highlights the importance of measuring serum potassium levels prior to initiating insulin therapy in DKA, judicious fluid and electrolyte management, as well as delaying and/or reducing insulin infusion rates in the setting of severe hypokalemia.
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Affiliation(s)
- Shanlee M Davis
- Children’s Hospital Colorado Pediatric Endocrinology, University of Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Children’s Hospital Colorado Intensive Care, University of Colorado Denver, Aurora, CO, USA
| | - Guy T Alonso
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Carol R Okada
- Children’s Hospital Colorado Intensive Care, University of Colorado Denver, Aurora, CO, USA
| | - Peter M Mourani
- Children’s Hospital Colorado Intensive Care, University of Colorado Denver, Aurora, CO, USA
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
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Poovazhagi V. Factors associated with mortality in children with diabetic ketoacidosis (DKA) in South India. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-015-0441-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Konstantinov NK, Rohrscheib M, Agaba EI, Dorin RI, Murata GH, Tzamaloukas AH. Respiratory failure in diabetic ketoacidosis. World J Diabetes 2015; 6:1009-1023. [PMID: 26240698 PMCID: PMC4515441 DOI: 10.4239/wjd.v6.i8.1009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/08/2015] [Accepted: 05/27/2015] [Indexed: 02/05/2023] Open
Abstract
Respiratory failure complicating the course of diabetic ketoacidosis (DKA) is a source of increased morbidity and mortality. Detection of respiratory failure in DKA requires focused clinical monitoring, careful interpretation of arterial blood gases, and investigation for conditions that can affect adversely the respiration. Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment. These conditions include deficits of potassium, magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema. Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system, pre-existing respiratory or neuromuscular disease and miscellaneous other conditions. Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.
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Warncke K, Dressel P, Ziegler AG, Steinborn M, Bonfig W, Burdach S, Engelsberger I. Severe pretreatment cerebral edema in newly diagnosed type 1 diabetes. Horm Res Paediatr 2015; 81:285-8. [PMID: 24642459 DOI: 10.1159/000357140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 11/05/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Cerebral edema (CE) is a rare and dangerous complication of diabetic ketoacidosis. In typical cases, it may develop during several hours after the beginning of ketoacidosis therapy. Nevertheless, CE sometimes occurs before the start of any therapy - as for the patient in this report here. CASE REPORT We describe a 12-year-old girl with newly diagnosed type 1 diabetes, presenting with severe headache and disorientation. Diabetes-related symptoms were not reported by the family. Clinical investigation revealed signs of meningeal irritation and Kussmaul breathing. In the laboratory, severe ketoacidosis (pH 6.95) and hyperglycemia (blood glucose 20.9 mmmol/l) were found. Cranial computed tomography showed CE. The patient was treated with a very cautious fluid and insulin therapy and recovered within 3 days. MRI after recovery showed normal findings without residuals of CE. CONCLUSION CE before any treatment of ketoacidosis is a very rare complication of type 1 diabetes. Early diagnosis and effective treatment are extremely important for the patient's outcome and prognosis.
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Affiliation(s)
- Katharina Warncke
- Department of Pediatrics, Kinderklinik München Schwabing, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Gómez Rivera N, García Zárate MG, Fonseca Chon I, Gómez Figueroa CO, Gómez Jiménez IA, Villalobos García L. [Diabetic ketoacidosis in children: hospital experience. A 15-year retrospective study]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2015; 72:313-317. [PMID: 29421529 DOI: 10.1016/j.bmhimx.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/11/2015] [Accepted: 09/13/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the major complications of diabetes mellitus (DM). The objective of this report was to highlight the clinical and laboratory importance in the treatment of patients with DKA during a 15-year period treated at the Hospital Infantil del Estado de Sonora (HIES). METHODS We retrospectively reviewed 140 patients with episodes of DKA to report clinical and laboratory features, mortality, and treatment with HIES protocol. RESULTS Mortality was 0%. Using descriptive statistics we observed minimal complications without neurologic sequelae in three patients with cerebral edema. CONCLUSIONS The HIES protocol is a practical and effective electrolyte and acid-base treatment for DKA.
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Varadarajan P, Suresh S. Delayed diagnosis of diabetic ketoacidosis in children—a cause for concern. Int J Diabetes Dev Ctries 2014. [DOI: 10.1007/s13410-014-0245-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Poovazhagi V. Risk factors for mortality in children with diabetic keto acidosis from developing countries. World J Diabetes 2014; 5:932-938. [PMID: 25512799 PMCID: PMC4265883 DOI: 10.4239/wjd.v5.i6.932] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/15/2014] [Accepted: 10/27/2014] [Indexed: 02/05/2023] Open
Abstract
Diabetic keto acidosis (DKA) is the major cause for mortality in children with Diabetes mellitus (DM). With increasing incidence of type 1 DM worldwide, there is an absolute increase of DM among children between 0-14 year age group and overall incidence among less than 30 years remain the same. This shift towards younger age group is more of concern especially in developing countries where mortality in DKA is alarmingly high. Prior to the era of insulin, DKA was associated with 100% mortality and subsequently mortality rates have come down and is now, 0.15%-0.31% in developed countries. However the scenario in developing countries like India, Pakistan, and Bangladesh are very different and mortality is still high in children with DKA. Prospective studies on DKA in children are lacking in developing countries. Literature on DKA related mortality are based on retrospective studies and are very recent from countries like India, Pakistan and Bangladesh. There exists an urgent need to understand the differences between developed and developing countries with respect to mortality rates and factors associated with increased mortality in children with DKA. Higher mortality rates, increased incidence of cerebral edema, sepsis, shock and renal failure have been identified among DKA in children from developing countries. Root cause for all these complications and increased mortality in DKA could be delayed diagnosis in children from developing countries. This necessitates creating awareness among parents, public and physicians by health education to identify symptoms of DM/DKA in children, in order to decrease mortality in DKA. Based on past experience in Parma, Italy it is possible to prevent occurrence of DKA both in new onset DM and in children with established DM, by simple interventions to increase awareness among public and physicians.
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Predictors of altered sensorium at admission in children with diabetic ketoacidosis. Indian J Pediatr 2014; 81:1163-6. [PMID: 24796411 DOI: 10.1007/s12098-014-1449-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 04/03/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To predict factors causing altered sensorium at admission in children with diabetic ketoacidosis (DKA). METHODS This retrospective study was done on 139 children with DKA who presented to Pediatric Emergency of a tertiary care hospital between January 2008 and November 2012. The case records were reviewed and information regarding personal details, clinical features, biochemical parameters and outcome was recorded. Statistical analyses were performed in small STATA version 12. Variables associated with altered sensorium in bivariate analysis (P < 0.05) were selected for inclusion in the multivariable logistic regression model. RESULTS Mean age was 8.04 ± 4.1 y; Male: Female ratio 0.75:1. The newly diagnosed diabetics were 54.6 % whereas rest were known diabetics. Eighty one percent children in severe DKA, 63 % moderate DKA and 18 % mild DKA had altered sensorium at admission. Univariate analysis revealed significant P values (P < 0.05) for pH and degree of dehydration. Results of final multivariate logistic regression revealed significant P values for pH (for pH 7.1-7.2, AOR-5.47, 95 % CI-1.24-24.1, P = 0.025 and for pH <7.1, AOR-14.19, 95 % CI - 4.13-48.7, P = 0.001) using pH >7.2 as the reference category. CONCLUSIONS Alteration in sensorium in children at initial admission with DKA is associated to low blood pH. ROC curve suggested good discrimination of pH for prediction of altered sensorium. The exact pathophysiologic mechanism of how low pH alters sensorium in DKA is still unknown and requires further studies.
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Prasad D, Arpita, Awasthi S. A retrospective case study of clinical profile of hospitalized children with type 1 diabetes mellitus at a tertiary health care center in northern India. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2013. [DOI: 10.1016/j.cegh.2013.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Palmiere C, Bardy D, Mangin P, Werner D. Postmortem diagnosis of unsuspected diabetes mellitus. Forensic Sci Int 2013; 226:160-7. [DOI: 10.1016/j.forsciint.2013.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 12/21/2012] [Accepted: 01/04/2013] [Indexed: 01/25/2023]
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