Improving management of diabetic ketoacidosis in children

Revised one-bag IV fluid protocol for pediatric DKA: a feasible approach and retrospective comparative study

BACKGROUND

This study compared the effectiveness of the traditional and revised one-bag protocols for pediatric diabetic ketoacidosis (DKA) management.

METHODS

This single-center retrospective cohort study included children diagnosed with DKA upon admission between 2012 and 2019. Our institution reevaluated and streamlined the traditional one-bag protocol (revised one-bag protocol). The revised one-bag protocol rehydrated all pediatric DKA patients with dextrose (5 g/100 ml) containing 0.45% NaCl at a rate of 3500 ml/m2 per 24 h after the first 1 h bolus of normal saline, regardless of age or degree of dehydration. This study examined acidosis recovery times and the frequency of healthcare provider interventions to maintain stable blood glucose levels.

RESULTS

The revised one-bag protocol demonstrated a significantly shorter time to acidosis recovery than the traditional protocol (12.67 and 18.20 h, respectively; p < 0.001). The revised protocol group required fewer interventions for blood glucose control, with an average of 0.25 dextrose concentration change orders per patient, compared to 1.42 in the traditional protocol group (p < 0.001). Insulin rate adjustments were fewer in the revised protocol group, averaging 0.52 changes per patient, vs. 2.32 changes in the traditional protocol group (p < 0.001).

CONCLUSION

The revised one-bag protocol for pediatric DKA is both practical and effective. This modified DKA management achieved acidosis recovery more quickly and reduced blood glucose fluctuations compared with the traditional one-bag protocol. Future studies, including randomized controlled trials, should assess the safety and effectiveness of the revised protocol in a broad range of pediatric patients with DKA.

Evaluation of the expression of genes associated with iron metabolism in peripheral blood mononuclear cells from Type 2 diabetes mellitus patients

AIMS

Type 2 Diabetes (T2DM) has been linked to ferroptosis. This study aimed to assess expression levels of genes linked with iron metabolism in peripheral blood mononuclear cells (PBMCs) from T2DM patients and to investigate the association of these expression levels with anthropometric and clinical parameters.

METHODS

Gene expression of iron metabolism genes (Ferritin Light Chain, FTL; Ferritin Heavy Chain, FTH1; Transferrin Receptor, TFRC; Divalent Metal Transporter 1, SLC11A2; Ferroportin, SLC40A1) in archival PBMCs was assessed using quantitative real-time PCR assays. Correlations of gene expression with anthropometric/biochemical patient data were evaluated.

RESULTS

The study included 36 (18 male/18 female) T2DM patients and 45 (28 male/17 female) normoglycemic (NGT) subjects with a mean age of 38.1 ± 6.8 years and 47.6 ± 8.6 years respectively. Relative expression of FTL was significantly lower in T2DM females compared to that in NGT females (P = 0.027). Relative expression of SLC40A1 was significantly lower in the T2DM group (P = 0.043) and in the T2DM females (P = 0.021). Relative expression of SLC11A2 was negatively correlated with systolic blood pressure in T2DM male patients. Relative expression of SLC40A1 was negatively associated with serum phosphorous and positively associated with serum thyroid stimulating hormone in male T2DM patients.

CONCLUSIONS

Our findings indicate a reduction in the expression of FTL in perimenopausal T2DM females. Also, in male T2DM patients and NGT subjects, biochemical markers are significantly correlated with the expression of FTL, FTH1, SLC11A2, and SLC40A1 in PBMCs.

Outcome of diabetic ketoacidosis among paediatric patients managed with modified DKA protocol at Tikur Anbessa specialized hospital and Yekatit 12 hospital, Addis Ababa, Ethiopia

INTRODUCTION

Diabetic ketoacidosis (DKA) is a serious acute complication of diabetes mellitus that carries a significant risk of mortality with delayed treatment in low-resource countries. This study aimed to determine the outcome of paediatric DKA patients' managed with a modified DKA treatment protocol using intermittent bolus subcutaneous insulin administration.

METHODS

A cross-sectional study design with retrospective data collection was conducted among children younger than 14 years of age admitted from January 2013 to February 2017. A modified protocol was prepared based on a reference from the international society for paediatric and adolescent diabetes and other international guidelines. Data were analysed using Statistical package for social science (SPSS) version 22.0. Descriptive statistics were performed. Binary logistic regression was used to identify associations, and significant variables were further considered for multivariate logistic regression to determine the outcome of DKA patients.

RESULT

Among the 190 patients, 55.5% (n = 105) were newly diagnosed. The overall average time required for resolution of DKA was 48 ± 27.8 h. Mental status on presentation (p = .001), shock on presentation (p < .01) and severity of DKA (p < .001) were found to have a significant association with the mean time for clearance of DKA. Hypoglycaemia was the most common treatment-related complication, which occurred in 23.7% of patients (n = 45) followed by hypokalaemia in 4.3% of patients (n = 8), and no patient developed cerebral oedema and death.

CONCLUSION

The time required for clearance of DKA was prolonged, and hypoglyceamia was a common complication for children younger than 5 years of age. The modified protocol of DKA is reasonable management for low-resource settings with further modification.

Evaluation of the Efficacy and Safety of 3 Different Management Protocols in Pediatric Diabetic Ketoacidosis

OBJECTIVE

Management protocols for pediatric diabetic ketoacidosis (DKA) vary considerably among medical centers. The aim of this study was to investigate the efficacy and safety of 3 different fluid protocols in the management of DKA.

METHODS

Fluid management protocols with sodium contents of 75, 100, and 154 mEq/L NaCl were compared. In all groups, after the initial rehydration, the protocols differed from each other in terms of the maintenance fluid, which had different rates of infusion and sodium contents. Clinical status and blood glucose levels were checked every hour during the first 12 hours. Biochemical tests were repeated at 2, 6, 12, 24, and 36 hours.

RESULTS

The medical records of 144 patients were evaluated. Cerebral edema developed in 18% of the patients. The incidence of cerebral edema was lowest in the group that received fluid therapy with a sodium content of 154 mEq/L NaCl at least 4 to 6 hours and had a constant rate of infusion for 48 hours. The patients with cerebral edema had lower initial pH and HCO3 and severe dehydration with higher initial plasma osmolality. There was no significant difference between the groups in terms of the recovery times of blood glucose, pH, HCO3, and the time of transition to subcutaneous insulin therapy.

CONCLUSIONS

Severity of acidosis and dehydration are associated with the development of cerebral edema. It can be concluded that fluid therapy with higher Na content and a constant maintenance rate may present less risk for the patient with DKA.

Brain injury in children with diabetic ketoacidosis: Review of the literature and a proposed pathophysiologic pathway for the development of cerebral edema

Cerebral edema (CE) is a potentially devastating complication of diabetic ketoacidosis (DKA) that almost exclusively occurs in children. Since its first description in 1936, numerous risk factors have been identified; however, there continues to be uncertainty concerning the mechanisms that lead to its development. Currently, the most widely accepted hypothesis posits that CE occurs as a result of ischemia-reperfusion injury, with inflammation and impaired cerebrovascular autoregulation contributing to its pathogenesis. The role of specific aspects of DKA treatment in the development of CE continues to be controversial. This review critically examines the literature on the pathophysiology of CE and attempts to categorize the findings by types of brain injury that contribute to its development: cytotoxic, vasogenic, and osmotic. Utilizing this scheme, we propose a multifactorial pathway for the development of CE in patients with DKA.

The Relationship Between Estimated Median Household Income and Critical Care Length of Stay in Children With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is an important diagnosis in the pediatric intensive care unit (PICU) and is associated with significant morbidity. We hypothesized children with DKA living in poorer communities would have unfavorable outcomes while critically ill. This single-center retrospective study included children with DKA admitted to a PICU over a 27-month period. Patients were classified as low-income if they lived in a ZIP code where the median household income was estimated to be less than 200% of the federal poverty threshold, or $48 016 for a family of 4. In this study, living in a low-income ZIP code was not associated with increased severity of illness, longer PICU length of stay (LOS), or readmission.

Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis

Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children's hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.

Fluid Therapy For Pediatric Patients With Diabetic Ketoacidosis: Current Perspectives

Diabetic ketoacidosis (DKA) is a preventable life-threatening complication of type 1 diabetes. Fluids form a crucial component of DKA therapy, goals being the restoration of intravascular, interstitial and intracellular compartments. Hydration reduces hyperglycemia by decreased counter-regulatory hormones, enhanced renal glucose clearance and augmented insulin sensitivity. However, for the last several decades, fluids in DKA have been subject of intense debate owing to their possible role in causation of cerebral edema (CE). Rehydration protocols have been modified to prevent major osmotic shifts, correct electrolyte imbalances and avoid cerebral or pulmonary edema. In DKA, a conservative deficit assumption ranging from 6.5% to 8.5% is preferred. Normal saline (0.9%) has been the traditional fluid of choice, for both, volume resuscitation and deficit replacement in DKA. However, the risk of AKI with its liberal chloride content remains a contentious issue. On the other hand, balanced crystalloids with restricted chloride content need more exploration in children with DKA, both with respect to DKA resolution and AKI. Although fluids are an integral part of DKA management, a fine balance is needed to avoid under-hydration or over-hydration during DKA management. In this narrative review, we discuss the current perspectives on fluids in pediatric DKA.

Presenting predictors and temporal trends of treatment-related outcomes in diabetic ketoacidosis

OBJECTIVE

This study examines temporal trends in treatment-related outcomes surrounding a diabetic ketoacidosis (DKA) performance improvement intervention consisting of mandated intensive care unit admission and implementation of a standardized management pathway, and identifies physical and biochemical characteristics associated with outcomes in this population.

METHODS

A retrospective cohort of 1225 children with DKA were identified in the electronic health record by international classification of diseases codes and a minimum pH less than 7.3 during hospitalization at a quaternary children's hospital between April, 2009 and May, 2016. Multivariable regression examined predictors and trends of hypoglycemia, central venous line placement, severe hyperchloremia, head computed tomography (CT) utilization, treated cerebral edema and hospital length of stay (LOS).

RESULTS

The incidence of severe hyperchloremia and head CT utilization decreased during the study period. Among patients with severe DKA (presenting pH < 7.1), the intervention was associated with decreasing LOS and less variability in LOS. Lower pH at presentation was independently associated with increased risk for all outcomes except hypoglycemia, which was associated with higher pH. Patients treated for cerebral edema had a lower presenting mean systolic blood pressure z score (0.58 [95% confidence interval (CI) -0.02-1.17] vs 1.23 [1.13-1.33]) and a higher maximum mean systolic blood pressure (SBP) z score during hospitalization (3.75 [3.19-4.31] vs 2.48 [2.38-2.58]) compared to patients not receiving cerebral edema treatment. Blood pressure and cerebral edema remained significantly associated after covariate adjustment.

CONCLUSION

Treatment-related outcomes improved over the entire study period and following a performance improvement intervention. The association of SBP with cerebral edema warrants further study.

Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital

OBJECTIVE

To review adherence to a provincial diabetic ketoacidosis (DKA) protocol and to assess factors associated with intravenous fluid administration and the length time on an insulin infusion.

METHODS

A retrospective chart review was conducted of all DKA admissions to British Columbia Children's Hospital (BCCH) during September 2008 to December 2013. Data collection included diabetes history, estimation of dehydration, insulin and fluid infusion rates, and frequency of laboratory investigations. Markers of adherence included appropriate use of a fluid bolus, normal saline and insulin infusion time, fluid intake and outputs, and the frequency of blood work during the insulin infusion. A log-linear regression model was fitted to assess the factors associated with insulin infusion duration.

RESULTS

Of 157 children (median [interquartile range] age: 10.6 years [5.0, 13.8]) hospitalized for DKA, 45% (n = 70) were male, 55% (n = 86) were transferred from other hospitals, and 26% (n = 40) were admitted to intensive care unit. Thirty-five percent of subjects estimated to have mild or moderate dehydration received fluid boluses. In the adjusted analysis, the average duration on DKA protocol was 39% (95% confidence interval [CI]: 12%, 67%) longer for children admitted with severe dehydration (compared to those with mild dehydration).

CONCLUSIONS

Health care providers' adherence to the BCCH DKA protocol is poor. More severe dehydration at presentation is associated with longer duration of insulin infusion. Further knowledge translation initiatives focused on accurate estimation of volume depletion to ensure appropriate initial fluid resuscitation-as well as careful monitoring during DKA hospitalization-are important, especially in community centers.

Identification of new key genes for type 1 diabetes through construction and analysis of protein-protein interaction networks based on blood and pancreatic islet transcriptomes

BACKGROUND

Type 1 diabetes (T1D) is an autoimmune disease in which pancreatic β-cells are destroyed by infiltrating immune cells. Bilateral cooperation of pancreatic β-cells and immune cells has been proposed in the progression of T1D, but as yet no systems study has investigated this possibility. The aims of the study were to elucidate the underlying molecular mechanisms and identify key genes associated with T1D risk using a network biology approach.

METHODS

Interactome (protein-protein interaction [PPI]) and transcriptome data were integrated to construct networks of differentially expressed genes in peripheral blood mononuclear cells (PBMCs) and pancreatic β-cells. Centrality, modularity, and clique analyses of networks were used to get more meaningful biological information.

RESULTS

Analysis of genes expression profiles revealed several cytokines and chemokines in β-cells and their receptors in PBMCs, which is supports the dialogue between these two tissues in terms of PPIs. Functional modules and complexes analysis unraveled most significant biological pathways such as immune response, apoptosis, spliceosome, proteasome, and pathways of protein synthesis in the tissues. Finally, Y-box binding protein 1 (YBX1), SRSF protein kinase 1 (SRPK1), proteasome subunit alpha1/ 3, (PSMA1/3), X-ray repair cross complementing 6 (XRCC6), Cbl proto-oncogene (CBL), SRC proto-oncogene, non-receptor tyrosine kinase (SRC), phosphoinositide-3-kinase regulatory subunit 1 (PIK3R1), phospholipase C gamma 1 (PLCG1), SHC adaptor protein1 (SHC1) and ubiquitin conjugating enzyme E2 N (UBE2N) were identified as key markers that were hub-bottleneck genes involved in functional modules and complexes.

CONCLUSIONS

This study provide new insights into network biomarkers that may be considered potential therapeutic targets.

Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids

BACKGROUND

Pediatric diabetic ketoacidosis (DKA) is a disease associated with several complications that can be severe. One complication includes cerebral edema (CE), and patients may experience significant morbidity with this disease.

OBJECTIVE

This review evaluates the myths concerning CE in pediatric DKA including mechanism, presentation of edema, clinical assessment of dehydration, and association with intravenous (i.v.) fluids.

DISCUSSION

Multiple complications may occur in pediatric DKA. CE occurs in < 1% of pediatric DKA cases, though morbidity and mortality are severe without treatment. Several myths surround this disease. Subclinical CE is likely present in many patients with pediatric DKA, though severe disease is rare. A multitude of mechanisms likely account for development of CE, including vasogenic and cytotoxic causes. Clinical dehydration is difficult to assess. Literature has evaluated the association of fluid infusion with the development of CE, but most studies are retrospective, with no comparator groups. The few studies with comparisons suggest fluid infusion is not associated with DKA. Rather, the severity of DKA with higher blood urea nitrogen and greater acidosis contribute to CE. Multiple strategies for fluid replacement exist. A bolus of 10 mL/kg of i.v. fluid is likely safe, which can be repeated if hemodynamic status does not improve.

CONCLUSIONS

Pediatric CE in DKA is rare but severe. Multiple mechanisms result in this disease, and many patients experience subclinical CE. Intravenous fluids are likely not associated with development of CE, and 10-mL/kg or 20-mL/kg i.v. bolus is safe.

Incidence, Trends, and Outcomes of Cerebral Edema Among Children With Diabetic Ketoacidosis in the United States

INTRODUCTION

There are limited data regarding the incidence, trends, and outcomes of cerebral edema among patients with diabetic ketoacidosis (DKA).

METHODS

NIS database was used from year 2002 to 2012. Cases with primary diagnosis of DKA were identified using International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9 CM) code 250.1 x. Cerebral edema patients were identified using ICD-9 CM code 348.5. We compared the baseline characteristics of both groups to estimate differences using the χ(2) test, Student's t test, Wilcoxon rank-sum test, and survey regression depending on the distributions of variables. For trend analysis, the χ(2) test of trend for proportions was used using the Cochrane Armitage test via the "trend" command in Statistical Analysis Software (SAS). Multivariate odds ratios were calculated. P value for <0.05 was considered as significant for all analysis.

RESULTS

In all, 205 (weighted n = 974) cases of cerebral edema were identified among 52 049 (weighted n = 246 925) DKA patients, which estimates the incidence of cerebral edema at 0.39%. Trends of incidence of developing cerebral edema increased almost 2 times, from 0.34 in 2002 to 0.64 in 2012 (P < 0.001). Univariate analysis showed that both length of stay (LOS; 3 vs 2; P < 0.001) and cost of hospitalization ($10 530 vs $3953; P < 0.001) were statistically higher among those who developed cerebral edema.

CONCLUSION

Our study shows that over the study period, trend in incidence of cerebral edema among DKA patients has increased. Patients with cerebral edema were found to have longer LOS and higher cost of hospitalization.

Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema

OBJECTIVE

To compare outcomes of diabetic ketoacidosis (DKA) 6 yrs before and 6 yrs after changing rehydration fluids from ½ normal saline to Lactated Ringer's and decreasing the total intended fluid volume administered in the first 24 hrs from 3500 mL/m(2) /d to ≤ 2500 mL/m(2) /d at Texas Children's Hospital (TCH) in response to recommendations by the ESPE, LWPES, and ISPAD in 2004.

SUBJECTS/METHODS

A retrospective cohort study was conducted in which 1868 admissions for DKA were identified and reviewed. The cohort was divided into two groups: Group A, 1998-2004, and Group B, 2004-2010. Subjects with suspected clinical cerebral edema and adverse outcomes were identified.

RESULTS

Although not statistically significant, there was an equal number (n = 3) of adverse outcomes (death or neurological damage) in each group despite more than double the admissions in Group B (1264) compared with those in Group A (604). Overall, the incidence of suspected clinical cerebral edema was more than double for those admissions in which fluid resuscitation was initiated at an outside hospital (OSH) vs. at TCH (13.6 vs. 5.3%, p < 0.001).

CONCLUSIONS

Decreasing the intended fluid rate during the initial 24 hrs to 2500 mL/m(2) /d and increasing the IV fluid sodium content did not significantly decrease the incidence of adverse outcomes in children with DKA. However, children transferred from an OSH had a higher incidence of suspected clinical cerebral edema. Thus, we need to more readily share our management protocols with the emergency rooms of local referring hospitals to potentially decrease the incidence of suspected clinical cerebral edema and adverse outcomes in children transferred with DKA.

Management of a patient with diabetic ketoacidosis in the emergency department

Diabetic ketoacidosis is a common problem among known and newly diagnosed diabetic children and adolescents for which they will often seek care in the emergency department (ED). Technological advances are leading to changes in outpatient management of diabetes. The ED physician needs to be aware of the new technologies in the care of diabetic children and comfortable managing patients using continuous subcutaneous insulin infusions. This article reviews the ED management of diabetic ketoacidosis and its associated complications, as well as the specific recommendations in caring for patients using the continuous subcutaneous insulin infusion, serum ketone monitoring, and continuous glucose monitoring.

The International Society of Pediatric and Adolescent Diabetes guidelines for management of diabetic ketoacidosis: Do the guidelines need to be modified?

The current version of the International Society of Pediatric and Adolescent Diabetes (ISPAD) guidelines for management of diabetic ketoacidosis (DKA) is largely based on the Lawson Wilkins Pediatric Endocrine Society/European Society of Pediatric Endocrinology (LWPES/ESPE) consensus statement on DKA in children and adolescents published in 2004. This article critically reviews and presents the most pertinent new data published in the past decade, which have implications for diagnosis and management. Four elements of the guidelines warrant modification: (i) The definition of DKA; (ii) insulin therapy; (iii) water and salt replacement; and (iv) blood ß-hydroxybutyrate measurements for the management of DKA.

Low morbidity and mortality in children with diabetic ketoacidosis treated with isotonic fluids

OBJECTIVE

To assess current rates of complications of diabetic ketoacidosis (DKA), particularly cerebral edema, in a large tertiary-care pediatric hospital with a consistent management protocol.

STUDY DESIGN

We report our single-center retrospective experience with 3712 admissions with DKA in 1999-2011. Our DKA protocol features a "3-bag" system using 2 bags of rehydration fluids, identical except for the presence in 1 bag of 10% dextrose, to allow rapid adjustment of glucose infusion rate. The third bag contains insulin. Fluids are administered at a total rate of 2-2.5 times "maintenance" fluid requirements. Total electrolyte concentration is kept approximately isotonic. Billing and medical records databases at Children's Medical Center Dallas were examined for cases of DKA, cerebral edema, other morbidities, and death.

RESULTS

We ascertained 20 cases of cerebral edema (0.5%). Most presented early (median duration of treatment 2 hours). Only 10 of 20 computed tomography scans were graded as moderate edema or worse. Only 10 patients received treatment other than routine DKA management. There was 1 death in a patient with sickle cell trait who developed intravascular sickling. Two patients had neurologic sequelae at hospital discharge but both recovered fully.

CONCLUSIONS

Compared with data in recent consensus statements, the Dallas protocol is associated with extremely low rates of death and disability (0.08% vs 0.3%) from DKA.

Evaluation of the two-bag system for fluid management in pediatric patients with diabetic ketoacidosis

OBJECTIVES

A one-bag and a two-bag system have both been used to manage intravenous fluid administration in pediatric patients with diabetic ketoacidosis (DKA). The one-bag system, however, has been noted to have limitations, such as slow response time. This study evaluates whether the two-bag system provides any clinical benefit in pediatric DKA patients as compared to the one-bag system.

METHODS

This was a retrospective, non-blinded chart review. Inclusion criteria were patients ≤ 18 years old and whose admission had the code of DKA as the diagnosis. Baseline clinical and demographic data were collected. Descriptive statistics were used in the data analysis.

RESULTS

A total of 31 patients were included, 9 (29%) in the one-bag group and 22 (71%) in the two-bag group. Baseline characteristics were similar between the two groups. Mean (SD) rate of complete blood glucose (CBG) correction was 31.04 mg/dL/hr (20.61) in the two-bag group and 21.04 mg/dL/hr (16.26) in the one-bag group (p = 0.297). The rate of bicarbonate correction, however, was faster with the two-bag system than the one-bag system (0.949 ± 0.553 mEq/L/hr and 0.606 ± 0.297 mEq/L/hr, respectively) (p = 0.047). The two-bag system also had a faster time to ketone (p = 0.04), but not pH (p = 0.172), correction.

CONCLUSIONS

The two-bag system provided a faster rate of bicarbonate and ketone correction compared to the one-bag system. The two-bag system also provided a trend towards a faster rate of blood glucose and pH correction.

Current concepts and controversies in prevention and treatment of diabetic ketoacidosis in children

Diabetic ketoacidosis (DKA) is caused by absolute or relative lack of insulin. Lack of insulin leads to hyperglycemia, ketonemia, and acidosis. Prevalence of DKA at diagnosis of type 1 diabetes (T1D) varies around the world from 18 % to 84 %. Incidence of recurrent DKA is higher among females, insulin pump users, those with a history of psychiatric or eating disorder, and suboptimal socioeconomic circumstances. DKA is the most common cause of death in children with T1D. Children with DKA should be treated in experienced centers. Initial bolus of 10-20 mL/kg 0.9 % saline is followed by 0.45 %-0.9 % saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours. The prevention of DKA at diagnosis of diabetes can be achieved by an intensive community intervention and education of health care providers to raise awareness. Prevention of recurrent DKA requires continuous patient education and access to diabetes programs and telephone services.

Measured degree of dehydration in children and adolescents with type 1 diabetic ketoacidosis

OBJECTIVE

Successful management of diabetic ketoacidosis depends on adequate rehydration while avoiding cerebral edema. Our objectives are to 1) measure the degree of dehydration in children with type 1 diabetes mellitus and diabetic ketoacidosis based on change in body weight; and 2) investigate the relationships between measured degree of dehydration and clinically assessed degree of dehydration, severity of diabetic ketoacidosis, and routine serum laboratory values.

DESIGN

Prospective observational study.

SETTING

University-affiliated tertiary care children's hospital.

PATIENTS

Sixty-six patients <18 yrs of age with type 1 diabetic ketoacidosis.

INTERVENTIONS

Patients were weighed using a portable scale at admission; 8, 16, and 24 hrs; and daily until discharge. Measured degree of dehydration was based on the difference between admission and plateau weights. Clinical degree of dehydration was assessed by physical examination and severity of diabetic ketoacidosis was assessed by blood gas values as defined by international guidelines. Laboratory values obtained on admission included serum glucose, urea nitrogen, sodium, and osmolality.

MEASUREMENTS AND MAIN RESULTS

Median measured degree of dehydration was 5.2% (interquartile range, 3.1% to 7.8%). Fourteen (21%) patients were clinically assessed as mild dehydration, 49 (74%) as moderate, and three (5%) as severe. Patients clinically assessed as moderately dehydrated had a greater measured degree of dehydration (5.8%; interquartile range, 3.6% to 9.6%) than those assessed as mildly dehydrated (3.7%; interquartile range, 2.3% to 6.4%) or severely dehydrated (2.5%; interquartile range, 2.3% to 2.6%). Nine (14%) patients were assessed as mild diabetic ketoacidosis, 18 (27%) as moderate, and 39 (59%) as severe. Diabetic ketoacidosis severity groups did not differ in measured degree of dehydration. Variables independently associated with measured degree of dehydration included serum urea nitrogen and sodium concentration on admission.

CONCLUSION

Hydration status in children with diabetic ketoacidosis cannot be accurately assessed by physical examination or blood gas values. Fluid therapy based on maintenance plus 6% deficit replacement is reasonable for most patients.

Sodium concentration in rehydration fluids for children with ketoacidotic diabetes: effect on serum sodium concentration

OBJECTIVES

To analyze in a retrospective cohort if sodium concentration in the rehydration fluids influence natremia in children with diabetic ketoacidosis (DKA).

STUDY DESIGN

Consecutive episodes of diabetic ketoacidosis admitted in a tertiary care referral center from 2000 to 2005. Rehydration was programmed for 48 hours with a 2-bag system. Initial rehydration was performed with isotonic fluids and thereafter with variable tonicity. Analysis of the influence of the different factors on natremia was performed with a multivariate linear regression analysis.

RESULTS

Forty-two episodes of DKA were reviewed. Increased sodium content in rehydration fluids behaved as an independent variable, causing a positive tendency of natremia (P < .008).

CONCLUSIONS

Sodium concentration in the rehydration fluids behaves as an independent factor that influences positively the trend of the serum concentration of sodium during DKA rehydration. We propose the use of isotonic solutions for rehydration in diabetic ketoacidosis.

Evaluation of the two-bag system for fluid management in pediatric patients with diabetic ketoacidosis

OBJECTIVES

A one-bag and a two-bag system have both been used to manage intravenous fluid administration in pediatric patients with diabetic ketoacidosis (DKA). The one-bag system, however, has been noted to have limitations, such as slow response time. This study evaluates whether the two-bag system provides any clinical benefit in pediatric DKA patients as compared to the one-bag system.

METHODS

This was a retrospective, non-blinded chart review. Inclusion criteria were patients ≤ 18 years old and whose admission had the code of DKA as the diagnosis. Baseline clinical and demographic data were collected. Descriptive statistics were used in the data analysis.

RESULTS

A total of 31 patients were included, 9 (29%) in the one-bag group and 22 (71%) in the two-bag group. Baseline characteristics were similar between the two groups. Mean (SD) rate of complete blood glucose (CBG) correction was 31.04 mg/dL/hr (20.61) in the two-bag group and 21.04 mg/dL/hr (16.26) in the one-bag group (p = 0.297). The rate of bicarbonate correction, however, was faster with the two-bag system than the one-bag system (0.949 ± 0.553 mEq/L/hr and 0.606 ± 0.297 mEq/L/hr, respectively) (p = 0.047). The two-bag system also had a faster time to ketone (p = 0.04), but not pH (p = 0.172), correction.

CONCLUSIONS

The two-bag system provided a faster rate of bicarbonate and ketone correction compared to the one-bag system. The two-bag system also provided a trend towards a faster rate of blood glucose and pH correction.

An evaluation of the outside therapy of diabetic ketoacidosis in pediatric patients

BACKGROUND

Despite literature outlining suggested initial therapy for pediatric patients with diabetic ketoacidosis (DKA), our impression has been that there may be variations from these recommendations during the initial therapy of pediatric patients with DKA. In order to improve education initiatives, an understanding of the deviations from current practice is required.

METHODS

Patients admitted to the pediatric intensive care unit with a diagnosis of DKA were identified from the admission log. The pre-pediatric intensive care unit care including laboratory evaluation, insulin dosing, and fluid therapy was recorded.

RESULTS

The study cohort included 135 episodes of DKA in 127 patients (age range: 10 months to 21 years). A complete blood count was obtained in 83.7% of the patients. Serum electrolytes, blood urea nitrogen, and creatinine were obtained in 89.6%, and a serum pH was obtained in 58%. Seventy-two patients received a bolus dose of insulin. The insulin bolus was < or =0.05 units/kg in 1 patient, >0.05 to < or =0.1 units/kg in 13 patients, >0.1 to < or =0.2 units/kg in 27 patients, and >0.2 units/kg in 31 patients. The route of administration for the insulin bolus was intravenous (IV) in 58 patients, a combination of IV and subcutaneous in 7 patients, subcutaneous in 6, and a combination of intramuscular and IV in 1 patient. Fluid administered before transport ranged from 0 to 60.6 mL/kg. Sixteen patients did not receive a fluid bolus. Normal saline was used in 115 patients, Ringer's lactate solution in 3, and 5% glucose in (1/2) normal saline in 1. Seventeen patients (12.6%) received IV sodium bicarbonate.

CONCLUSIONS

Major issues with the prehospital care of children and adolescents with DKA included lack of appropriate laboratory evaluation, excessive insulin dosing (both bolus doses and infusion rates), lack of fluid resuscitation, use of inappropriate fluids for resuscitation, and the use of sodium bicarbonate.

Diabetic ketoacidosis: a current appraisal of pathophysiology and management

Diabetic ketoacidosis (DKA) is a frequent abnormal metabolic entity seen in high-dependency units such as critical care units and in the emergency department. Having an understanding of its pathophysiology, a consequence of absent to low insulin levels, delineates the clinical presentation. Most clinical features are caused by hyperglycemia and acidosis, including weight loss. The newer management modalities are discussed that include the need for intensive laboratory workup, meticulous monitoring of the insulin, and fluid management. Among the complications, cerebral edema (CE) is the most dreaded, albeit with low incidence. The new insights into its pathophysiology and management are outlined, and a timeline for management of DKA is proposed.

Cerebral edema in diabetic ketoacidosis

OBJECTIVE

To review the causes of cerebral edema in diabetic ketoacidosis (CEDKA), including pathophysiology, risk factors, and proposed mechanisms, to review the diagnosis, treatment, and prognosis of CEDKA and the treatment of diabetic ketoacidosis as it pertains to prevention of cerebral edema.

DATA SOURCE

A MEDLINE search using OVID was done through 2006 using the search terms cerebral edema and diabetic ketoacidosis. RESULTS OF SEARCH: There were 191 citations identified, of which 150 were used. An additional 42 references listed in publications thus identified were also reviewed, and two book chapters were used.

STUDY SELECTION

The citations were reviewed by the author. All citations identified were used except 25 in foreign languages and 16 that were duplicates or had inappropriate titles and/or subject matter. Of the 194 references, there were 21 preclinical and 40 clinical studies, 35 reviews, 15 editorials, 43 case reports, 29 letters, three abstracts, six commentaries, and two book chapters.

DATA SYNTHESIS

The data are summarized in discussion.

CONCLUSIONS

The causes and mechanisms of CEDKA are unknown. CEDKA may be due as much to individual biological variance as to severity of underlying metabolic derangement of the child's state and/or treatment risk factors. Treatment recommendations for CEDKA and diabetic ketoacidosis are made taking into consideration possible mechanisms and risk factors but are intended as general guidelines only in view of the absence of conclusive evidence.

Gene expression in peripheral blood mononuclear cells from children with diabetes

OBJECTIVE

We hypothesized that type 1 diabetes (T1D) is accompanied by changes in gene expression in peripheral blood mononuclear cells due to dysregulation of adaptive and innate immunity, counterregulatory responses to immune dysregulation, insulin deficiency, and hyperglycemia.

RESEARCH DESIGN AND METHODS

Microarray analysis was performed on peripheral blood mononuclear cells from 43 patients with newly diagnosed T1D, 12 patients with newly diagnosed type 2 diabetes (T2D), and 24 healthy controls. One- and 4-month follow-up samples were obtained from 20 of the T1D patients.

RESULTS

Microarray analysis identified 282 genes differing in expression between newly diagnosed T1D patients and controls at a false discovery rate of 0.05. Changes in expression of IL1B, early growth response gene 3, and prostaglandin-endoperoxide synthase 2 resolved within 4 months of insulin therapy and were also observed in T2D, suggesting that they resulted from hyperglycemia. With use of a knowledge base, 81 of 282 genes could be placed within a network of interrelated genes with predicted functions including apoptosis and cell proliferation. IL1B and the MYC oncogene were the most highly connected genes in the network. IL1B was highly overexpressed in both T1D and T2D, whereas MYC was dysregulated only in T1D.

CONCLUSION

T1D and T2D likely share a final common pathway for beta-cell dysfunction that includes secretion of IL-1beta and prostaglandins by immune effector cells, exacerbating existing beta-cell dysfunction, and causing further hyperglycemia. The results identify several targets for disease-modifying therapy of diabetes and potential biomarkers for monitoring treatment efficacy.

Treatment of diabetic ketoacidosis in adults in Denmark: a national survey

The aims of this study were to investigate management routines of diabetic ketoacidosis (DKA) in adult patients in departments of internal medicine in Denmark and to relate current routines of treatment to available evidence. A questionnaire requesting information on management routines of DKA was sent to all departments of internal medicine in Denmark responsible of managing DKA. Fifty-nine departments (88%) returned the questionnaire and/or a copy of their management protocol. At 19 departments (32%), all patients with DKA were managed in an intensive care unit (ICU). Twenty-four different insulin regimens and 21 fluid protocols were identified. Routines of insulin therapy varied in terms of doses and routes of administration. Fifty-eight departments (97%) used isotonic saline for hydration. Potassium supplements were administered as a separate infusion of either isotonic potassium-sodium-chloride (83%) or isotonic potassium-chloride (10%). Recommended volumes to be administered during the first 8h of treatment varied significantly (median 4800ml, range 3750-7700ml). Use of bicarbonate was endorsed by 80%. This study shows significant variations in management routines of DKA in Denmark. In many cases, the treatment routines employed are not supported by evidence from clinical trials. We recommend implementation of national and/or European guidelines for management of DKA in adult patients.

Preventing a drop in effective plasma osmolality to minimize the likelihood of cerebral edema during treatment of children with diabetic ketoacidosis

OBJECTIVES

To test whether a drop in effective plasma osmolality (P(Eff osm); 2 x plasma sodium [P(Na)] + plasma glucose concentrations) during therapy for diabetic ketoacidosis (DKA) is associated with an increased risk of cerebral edema (CE), and whether the development of hypernatremia to prevent a drop in the P(Eff osm) is dangerous.

STUDY DESIGN

This study is a retrospective comparison of a CE group (n = 12) and non-CE groups with hypernatremia (n = 44) and without hypernatremia (n = 13).

RESULTS

The development of CE (at 6.8 +/- 1.5 hours) was associated with a drop in P(Eff osm) from 304 +/- 5 to 290 +/- 5 mOsm/kg (P < .001). Control patients did not show this drop in P(Eff osm) at 4 hours (1 +/- 2 and 2 +/- 2 vs -9 +/- 2 mOsm/kg; P < .01), because of a larger rise in P(Na) and/or a smaller drop in plasma glucose. During this period, the CE group received more near-isotonic fluids (69 +/- 9 vs 35 +/- 2 and 27 +/- 3 mL/kg; P < .001). The CE group had a higher mortality (3/12 vs 0/57; P = .003), and more neurologic sequelae (5/12 vs 1/57; P < .001).

CONCLUSIONS

CE during therapy for DKA was associated with a drop in P(Eff osm). An adequate rise in P(Na) may be needed to prevent this drop in P(Eff osm).

Serum Glucose Changes During Insulin Therapy in Pediatric Patients With Diabetic Ketoacidosis

There are limited data on which to base insulin dosing schemes for diabetic ketoacidosis (DKA). The goal of therapy is to avoid excessive decreases in serum glucose (greater than 100 mg/dL/h) because of the risks of rapid changes in serum osmolarity and the potential risk of cerebral edema. We retrospectively reviewed the therapy of DKA in pediatric patients admitted to our Pediatric Intensive Care Unit over the past 10 years. There were 35 patients who received IV bolus insulin therapy (0.08 to 1.6 units/kg, 0.24 +/- 0.27 units/kg). The serum-glucose decrease was less than or equal to 100 mg/dL in 10 patients, 101 to 200 mg/dL in 13 patients, 201 to 300 mg/dL in 8 patients, 301 to 400 mg/dL in 2 patients, and more than 500 mg/dL in 2 patients. In patients who received 0.05 to 0.1 units/kg of insulin as a bolus dose, the decrease in serum glucose was greater than 100 mg/dL in 5 of 11 patients. An insulin infusion was administered to 91 patients. During the 243 hours of insulin infusion therapy, the decline in serum glucose was 0 to 100 mg/dL during 162 hours, 101 to 200 mg/dL during 49 hours, 201 to 300 mg/dL during 8 hours, and more than 300 mg/dL during 3 hours. Of the 193 hours of 0.05 to 0.1 units/kg/h insulin administration, there were 47 hours (24%) during which the serum-glucose decrease was greater than 100 mg/dL. Of the 21 hours of insulin administration at less than 0.05 units/kg/h, there was 1 hour (4.8%) where the serum-glucose decrease was greater than 100 mg/dL (P = 0.05 vs. insulin infusion at 0.05 to 0.1 units/kg/h). Commonly used insulin dosing regimens of a bolus of 0.1 units/kg followed by an infusion of 0.05 to 0.1 units/kg/h frequently resulted in a decrease in serum glucose of greater than 100 mg/dL/h. Prospective trials are needed to more accurately define appropriate insulin dosing regimens for pediatric patients with DKA.

The anion gap (AG): studies in the nephrotic syndrome and diabetic ketoacidosis (DKA)

Although "unmeasured" anions contribute to metabolic acidosis in a variety of disease states, they are generally not measured directly but estimated from the calculation of "gaps." Among the most commonly used method, the anion gap (AG) is not only a function of "unmeasured" anions, but also it is a function of plasma non-carbonate buffers (albumin and phosphate), the plasma pH, and the method of measurement. To clarify the contribution of non-carbonate buffers to the AG, the Figge-Fencl-Waston model of human plasma was applied to laboratory values obtained from two novel populations, patients with nephrotic syndrome and patients with diabetic ketoacidosis (DKA). The model performed adequately, justifying the common clinical practice of correcting the AG for the net protein charge.

Diabetic ketoacidosis in the pediatric ICU

Diabetic ketoacidosis (DKA), a pathophysiologic, life-threatening process that results from uncontrolled diabetes mellitus-induced hyperglycemia, is seen frequently in the pediatric ICU. This article reviews the pathophysiology, management, goals of treatment, and nursing implications of the child who is diagnosed with DKA. Facets particular to the pediatric population are reviewed.

Diabetic ketoacidosis in children

Although diabetic ketoacidosis should, theoretically, be largely preventable in patients with established diabetes, a recent report from a major US childhood diabetes center showed that children with type 1 diabetes remain at high risk for diabetic ketoacidosis, with an incidence of 8 per 100 patient-years. Children who are uninsured or underinsured, have psychiatric disorders, have poorly controlled diabetes, and live in dysfunctional families are most vulnerable. The efficacy and cost effectiveness of strategies to reduce the incidence of diabetic ketoacidosis-before diagnosis and in patients with established diabetes-are important issues for future investigation.

Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis

OBJECTIVES

To determine incidence, outcomes, and risk factors for pediatric cerebral edema with diabetic ketoacidosis (CEDKA) in Canada.

STUDY DESIGN

This was a case-control study nested within a population-based active surveillance study of CEDKA in Canada from July 1999 to June 2001. Cases are patients with DKA <16 years of age with cerebral edema. Two unmatched control subjects per case are patients with DKA without cerebral edema.

RESULTS

Thirteen cases of CEDKA were identified over the surveillance period for an incidence rate of 0.51%; 23% died and 15% survived with neurologic sequelae. CEDKA was present at initial presentation of DKA in 19% of cases. CEDKA was associated with lower initial bicarbonate ( P = .001), higher initial urea ( P = .001), and higher glucose at presentation ( P = .014). Although there was a trend to association with higher fluid rates and treatment with bicarbonate, these were not independent predictors.

CONCLUSIONS

CEDKA remains a significant problem with a high mortality rate. No association was found between the occurrence of CEDKA and treatment factors. The presence of cerebral edema before treatment of DKA and the association with severity of illness suggest that prevention of DKA is the key to avoiding this devastating complication.

Cerebral oedema in childhood diabetic ketoacidosis: is treatment a factor?

Cerebral oedema (CO) is the most dreaded complication of diabetic ketoacidosis (DKA) in children. Despite advances in many areas of the management of DKA, the mortality from CO has remained constant for decades. This rare disorder, complicating about 1% of cases of DKA in children, is lethal in 20% to 50% of victims. Since it was first described in 1936, much effort has gone into the search for a cause for this condition, but CO in childhood DKA remains a mysterious illness. Researchers have suggested that the treatment for DKA may be causally related to the development of CO. Others have disputed this claim, and both camps cite evidence to support their point of view. This article reviews the literature pertinent to the question: Is the treatment of DKA in children responsible for the development of CO?

Bedside ketone determination in diabetic children with hyperglycemia and ketosis in the acute care setting

OBJECTIVE

Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus marked by characteristic biochemical derangements. Diagnosis and management involve frequent evaluation of these biochemical parameters. Reliable bedside equivalents for these laboratory studies may help reduce the time to treatment and reduce costs.

METHODS

We evaluated the precision and bias of a bedside serum ketone meter in the acute care setting. Serum ketone results using the Precision Xtra glucometer/ketone meter (Abbott Laboratories, MediSense Products Inc., Bedford, MA, USA) correlated strongly with the Children's Medical Center of Dallas' laboratory values within the meter's value range.

RESULTS

Meter ketone values steadily decreased during the treatment of DKA as pH and CO(2) levels increased and acidosis resolved.

CONCLUSION

Therefore, the meter may be useful in monitoring therapy for DKA. This meter may also prove useful in identifying patients at risk for DKA in physicians' offices or at home.

ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.