Journal Article

VARIABILITY IN EMERGENT MANAGEMENT OF DIABETIC KETOACIDOSIS IN PEDIATRICS: A RETROSPECTIVE CHART REVIEW

Zoyah Thawer, David Saleh and Keith Gregoire

in Paediatrics & Child Health

Published on behalf of Canadian Paediatric Society

Volume 23, issue suppl_1 Published in print May 2018 | ISSN: 1205-7088
Published online May 2018 | e-ISSN: 1918-1485 | DOI: https://dx.doi.org/10.1093/pch/pxy054.029
VARIABILITY IN EMERGENT MANAGEMENT OF DIABETIC KETOACIDOSIS IN PEDIATRICS: A RETROSPECTIVE CHART REVIEW

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  • Neonatology
  • Primary Care
  • Child and Adolescent Psychiatry
  • Clinical Child and Adolescent Psychology
  • Developmental Psychology

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Abstract

BACKGROUND

Variability in the management of paediatric diabetic ketoacidosis (DKA) has been well described in the literature. Although there are many paediatric DKA management guidelines available at tertiary care centres, there seems to be a lack of familiarity with these in some community hospitals, leading to management inconsistent with evidence-based clinical practice.

OBJECTIVES

Our objectives were to review the management of paediatric patients who present in DKA, identify those that received initial emergent treatment not consistent with current guidelines, and track associated complications.

DESIGN/METHODS

Forty-seven charts of paediatric patients admitted to our institution (including patients transferred from peripheral hospitals) from January, 2012 to July, 2017 were identified by ICD-10 codes containing “ketoacidosis”. Primary outcome measures for inadequate management included major risk factors for cerebral edema - IV insulin boluses, IV bicarbonate boluses, hypo-osmolar IV fluid administration and non-NPO status - as well as inappropriate IV fluid boluses>10mL/kg, insulin infusion initiated within the first hour after IV fluids were initiated, and inadequate potassium replacement.

RESULTS

At least one area of inadequate management occurred at a rate of 74.5% with no significant difference between community hospitals and our tertiary centre. The most common parameter was inadequate replacement of potassium (44.7%), followed by receiving an IV fluid bolus>10mL/kg (40.4%). Twenty-three percent of patients received inadequate management that included a treatment-related major risk factor for cerebral edema. The most common complication was hypoglycemia (BG<4.0mM; 14.9%) and there were no cases of cerebral edema or patients that received a CT head. Though the mean time to insulin infusion initiation was 4.0 hours at outside centres and 2.8 hours at our tertiary centre, the difference was not statistically significant (p=0.26). However, there was a statistically significant difference in time to correction of acidosis, with correction of DKA happening more quickly at our tertiary centre (9.5h compared to 12.7h at outside centres; p=0.03).

CONCLUSION

Optimal paediatric DKA management continues to be a challenge despite the presence of multiple, evidence-based guidelines. Gradual resuscitation with appropriate fluids appears to be the most common area in which variability exists in community and tertiary care centres.

Journal Article.  0 words. 

Subjects: Neonatology ; Primary Care ; Child and Adolescent Psychiatry ; Clinical Child and Adolescent Psychology ; Developmental Psychology

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