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Belal MM, Khalefa BB, Rabea EM, Aly Yassin MN, Bashir MN, Abd El-Hameed MM, Elkoumi O, Saad SM, Saad LM, Elkasaby MH. Low dose insulin infusion versus the standard dose in children with diabetic ketoacidosis: a meta-analysis. Future Sci OA 2024; 10:FSO956. [PMID: 38827803 PMCID: PMC11140676 DOI: 10.2144/fsoa-2023-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/13/2023] [Indexed: 06/05/2024] Open
Abstract
Aim: This systematic review aims to consolidate findings from current clinical trials that compare the effectiveness of insulin infusion at 0.05 IU/kg/h versus 0.1 IU/kg/h in managing pediatric diabetic ketoacidosis. Methods: We searched several databases, including PubMed, Embase, Scopus, Cochrane Central and Web of Science. Our primary outcomes were time to reach blood glucose ≤250 mg/dl and time to resolution of acidosis. Secondary outcomes included rate of blood glucose decrease per hour, incidence of hypoglycemia, hypokalemia, treatment failure, and cerebral edema. Results & conclusion: The present study establishes that a low insulin dose exhibits comparable efficacy to the standard dosage for managing pediatric patients suffering from diabetic ketoacidosis, with a lower incidence of complications.
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Affiliation(s)
- Mohamed Mohamed Belal
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Basma Badrawy Khalefa
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Ain shams University, Cairo, Egypt
| | - Eslam Mohammed Rabea
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mazen Negmeldin Aly Yassin
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed Nabih Bashir
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Malak Mohamed Abd El-Hameed
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Ash Sharqia, Egypt
| | - Omar Elkoumi
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Suez University, Suez, Egypt
| | - Saad Mohamed Saad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Loubna Mohamed Saad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mohamed Hamouda Elkasaby
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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2
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Scutca AC, Nicoară DM, Mang N, Jugănaru I, Brad GF, Mărginean O. Correlation between Neutrophil-to-Lymphocyte Ratio and Cerebral Edema in Children with Severe Diabetic Ketoacidosis. Biomedicines 2023; 11:2976. [PMID: 38001976 PMCID: PMC10669654 DOI: 10.3390/biomedicines11112976] [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: 10/02/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
Diabetic ketoacidosis (DKA), a common onset modality of type 1 diabetes mellitus (T1DM), can lead, in rare instances, to the development of cerebral edema, which is the leading cause of mortality in T1DM. Aside from the identification of several demographic and clinical risk factors for cerebral edema, attention has also been drawn to the possible link between systemic inflammation and neuroinflammation. This single-center retrospective study of 98 children with severe DKA aimed to investigate the possible relationship between neutrophil-to-lymphocyte ratio NLR) levels and the presence of cerebral edema. Patients were classified into three groups: alert (n = 28), subclinical cerebral edema (n = 59), and overt cerebral edema (n = 11). Lower blood pH and elevated NLR and blood urea were correlated with the presence of cerebral edema (p < 0.001). After a multivariable risk adjustment for possible confounding factors, such as age, pH, corrected sodium, and BUN, the NLR remained positively associated with cerebral edema (p = 0.045). As such, NLR may be an additional instrument to help practitioners target patients with a higher risk of severe cerebral edema. These patients would benefit from more rigorous neurologic surveillance, enabling the prompt identification of early signs of cerebral edema.
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Affiliation(s)
- Alexandra-Cristina Scutca
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
| | - Delia-Maria Nicoară
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
| | - Niculina Mang
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
| | - Iulius Jugănaru
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Giorgiana-Flavia Brad
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
| | - Otilia Mărginean
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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3
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Wardi G, Holgren S, Gupta A, Sobel J, Birch A, Pearce A, Malhotra A, Tainter C. A Review of Bicarbonate Use in Common Clinical Scenarios. J Emerg Med 2023; 65:e71-e80. [PMID: 37442665 PMCID: PMC10530341 DOI: 10.1016/j.jemermed.2023.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/29/2023] [Accepted: 04/10/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND The use of sodium bicarbonate to treat metabolic acidosis is intuitive, yet data suggest that not all patients benefit from this therapy. OBJECTIVE In this narrative review, we describe the physiology behind commonly encountered nontoxicologic causes of metabolic acidosis, highlight potential harm from the indiscriminate administration of sodium bicarbonate in certain scenarios, and provide evidence-based recommendations to assist emergency physicians in the rational use of sodium bicarbonate. DISCUSSION Sodium bicarbonate can be administered as a hypertonic push, as a resuscitation fluid, or as an infusion. Lactic acidosis and cardiac arrest are two common scenarios where there is limited benefit to routine use of sodium bicarbonate, although certain circumstances, such as patients with concomitant acute kidney injury and lactic acidosis may benefit from sodium bicarbonate. Patients with cardiac arrest secondary to sodium channel blockade or hyperkalemia also benefit from sodium bicarbonate therapy. Recent data suggest that the use of sodium bicarbonate in diabetic ketoacidosis does not confer improved patient outcomes and may cause harm in pediatric patients. Available evidence suggests that alkalinization of urine in rhabdomyolysis does not improve patient-centered outcomes. Finally, patients with a nongap acidosis benefit from sodium bicarbonate supplementation. CONCLUSIONS Empiric use of sodium bicarbonate in patients with nontoxicologic causes of metabolic acidosis is not warranted and likely does not improve patient-centered outcomes, except in select scenarios. Emergency physicians should reserve use of this medication to conditions with clear benefit to patients.
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Affiliation(s)
- Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, San Diego, California; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California.
| | - Sarah Holgren
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology. University of California at San Diego, San Diego, California
| | - Arnav Gupta
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Julia Sobel
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Aaron Birch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California
| | - Alex Pearce
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California
| | - Christopher Tainter
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology. University of California at San Diego, San Diego, California
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4
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Gripp KE, Trottier ED, Thakore S, Sniderman J, Lawrence S. Les recommandations en vigueur pour la prise en charge de l'acidocétose diabétique pédiatrique. Paediatr Child Health 2023; 28:128-138. [PMID: 37151921 PMCID: PMC10156930 DOI: 10.1093/pch/pxac120] [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: 07/29/2021] [Accepted: 06/20/2022] [Indexed: 05/09/2023] Open
Abstract
Pour traiter l'acidocétose diabétique pédiatrique, il faut porter une attention particulière aux liquides et aux électrolytes pour limiter le risque de complications, telles qu'une lésion cérébrale, associée à une morbidité et une mortalité élevées. L'incidence d'œdème cérébral en cas d'acidocétose diabétique n'a pas diminué malgré les protocoles visant la limitation des liquides qui s'appuient sur la restriction de la réanimation liquidienne initiale. Selon de nouvelles données probantes, l'administration précoce de liquides isotoniques n'entraîne pas de risque supplémentaire et peut améliorer les résultats cliniques chez certains patients. Les protocoles et les directives cliniques sont adaptés et axés particulièrement sur la surveillance et le remplacement initiaux et continus des liquides et des électrolytes. Il est maintenant recommandé de commencer par une réanimation à l'aide de liquides isotoniques chez tous les patients dans les 20 à 30 minutes suivant leur arrivée à l'hôpital, suivie par la réplétion du déficit volumique sur une période de 36 heures, en association avec une perfusion d'insuline et des suppléments d'électrolytes, ainsi qu'avec la surveillance et la prise en charge attentives d'une éventuelle lésion cérébrale.
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Affiliation(s)
- Karen E Gripp
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Evelyne D Trottier
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Sidd Thakore
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Jonathan Sniderman
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
| | - Sarah Lawrence
- Société canadienne de pédiatrie, comité des soins aigus, Ottawa (Ontario)Canada
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5
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Gripp KE, Trottier ED, Thakore S, Sniderman J, Lawrence S. Current recommendations for management of paediatric diabetic ketoacidosis. Paediatr Child Health 2023; 28:128-138. [PMID: 37151932 PMCID: PMC10156932 DOI: 10.1093/pch/pxac119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 06/20/2022] [Indexed: 05/09/2023] Open
Abstract
Treatment of paediatric diabetic ketoacidosis (DKA) includes careful attention to fluids and electrolytes to minimize the risk of complications such as cerebral injury (CI), which is associated with high morbidity and mortality. The incidence of cerebral edema in paediatric DKA has not decreased despite the use of fluid-limiting protocols based on restricting early fluid resuscitation. New evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes in some patients. Protocols and clinical practice guidelines are being adjusted, with a particular focus on recommendations for initial and ongoing fluids and electrolyte monitoring and replacement. Initial isotonic fluid resuscitation is now recommended for all patients in the first 20 to 30 minutes after presentation, followed by repletion of volume deficit over 36 hours in association with an insulin infusion, electrolyte supplementation, and careful monitoring for and management of potential CI.
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Affiliation(s)
- Karen E Gripp
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Evelyne D Trottier
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Sidd Thakore
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Jonathan Sniderman
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
| | - Sarah Lawrence
- Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario, Canada
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6
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Azova S, Liu E, Wolfsdorf J. Increased Use of Hyperosmolar Therapy for Suspected Clinically Apparent Brain Injury in Pediatric Patients with Diabetic Ketoacidosis during the Peak of the COVID-19 Pandemic. Pediatr Diabetes 2023; 2023:5123197. [PMID: 38050487 PMCID: PMC10695073 DOI: 10.1155/2023/5123197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Abstract
The incidence of pediatric diabetic ketoacidosis (DKA) increased during the peak of the COVID-19 pandemic. The objective of this study was to investigate whether rates of hyperosmolar therapy administration for suspected clinically apparent brain injury (CABI) complicating DKA also increased during this period as compared to the three years immediately preceding the pandemic and to compare the characteristics of patients with suspected CABI before the pandemic, patients with suspected CABI during the peak of the pandemic, and those with DKA but without suspected CABI during the pandemic. Patients aged ≤18 years presenting with DKA before (March 11, 2017-March 10, 2020) and during the peak of the pandemic (March 11, 2020-March 10, 2021) were identified through a rigorous search of two databases. Predefined criteria were used to diagnose suspected CABI. Biochemical, clinical, and sociodemographic data were collected from a comprehensive review of the electronic medical record. The proportion of patients with DKA who received hyperosmolar therapy was significantly higher (P = 0.014) during the pandemic compared to the prepandemic period; however, this was only significant among patients with newly diagnosed diabetes. Both groups with suspected CABI had more severe acidosis, lower Glasgow Coma Scale scores, and longer hospital admissions (P< 0.001 for all) than cases without suspected CABI. During the pandemic, the blood urea nitrogen concentration was significantly higher in patients with suspected CABI than those without suspected CABI, suggesting they were more severely dehydrated. The clinical, biochemical, and sociodemographic characteristics of patients with suspected CABI were indistinguishable before and during the pandemic. In conclusion, administration of hyperosmolar therapy for suspected CABI was more common during the peak of the COVID-19 pandemic, possibly a result of delayed presentation, highlighting the need for increased awareness and early recognition of the signs and symptoms of diabetes and DKA, especially during future surges of highly transmissible infections.
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Affiliation(s)
- Svetlana Azova
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts 02115, USA
| | - Joseph Wolfsdorf
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA
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7
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Raleigh ZT, Drapkin ZA, Al-Hamad DM, Mutyala K, Masih JR, Raman VS. Outcomes of children with severe diabetic ketoacidosis managed outside of a pediatric intensive care unit. J Pediatr Endocrinol Metab 2023; 36:174-178. [PMID: 36473079 DOI: 10.1515/jpem-2022-0457] [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: 09/12/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes. Our objective was to determine if children with severe DKA without alteration in mental status can be managed safely on a general children's medical unit. METHODS Single center retrospective study of 191 patient encounters among 168 children admitted to the children's medical unit (CMU) at Primary Children's Hospital between 2007 and 2017 with severe DKA (pH <7.1 and/or bicarbonate <5 mmol/L). Chart review identified complications including death, transfer to the intensive care unit (ICU), incidence of cerebral edema, and hypoglycemia. We compared patients requiring ICU transfer with those who did not with respect to demographics, laboratory findings at presentation, therapeutic interventions, length of stay, and cost. RESULTS Of 191 patient encounters, there were 0 deaths (0%, 95% CI 0-2.4%), 22 episodes of alteration of mental status concerning for developing cerebral edema (11.5%, 95% CI 7.7-16.9%), 19 ICU transfers (10%, 95% CI 6.4-15.1%), and 7 episodes of hypoglycemia (3.7%, 95% CI 1.6-7.5%). ICU transfer was associated lower initial pH (7.03 ± 0.06 vs. 7.07 ± 0.07, p<0.05), increased length of stay (3.0 ± 0.8 vs. 2.2 ± 0.9 days, p<0.05), and increased cost of hospitalization (mean ± SD $8,073 ± 2,042 vs. $5,217 ± 1,697, p<0.05). CONCLUSIONS The majority of children with severe DKA without alteration in mental status can be managed safely on a medical unit. Implementing a pH cutoff may identify high-risk patients that require ICU level of care.
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Affiliation(s)
- Zoe T Raleigh
- Division of Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Zachary A Drapkin
- Division of Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Dania M Al-Hamad
- Division of Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Krishnamallika Mutyala
- Division of Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jasmine R Masih
- Division of Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Vandana S Raman
- Division of Endocrinology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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8
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Bergmann KR, Boes M, Velden HV, Abuzzahab MJ, Watson D. Intravenous Fluid Bolus Volume and Resolution of Acute Kidney Injury in Children With Diabetic Ketoacidosis. Pediatr Emerg Care 2023; 39:67-73. [PMID: 36719386 DOI: 10.1097/pec.0000000000002616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe trends in creatinine and acute kidney injury (AKI) in children who present with diabetic ketoacidosis (DKA) and receive low versus high intravenous (IV) fluid bolus volumes. Further, to determine whether resolution of AKI is hastened by low versus high bolus volumes. METHODS We conducted an observational retrospective cohort study between January 2012 and March 2020 among children ≤21 years presenting with DKA. Acute kidney injury was defined by the Kidney Disease/Improving Global Outcomes creatinine criteria, using the Schwartz estimating equation to calculate an expected baseline creatinine. Bolus volume was categorized as low (<15 mL/kg) or high (≥15 mL/kg). Generalized additive mixed models were used to model trends of creatinine ratios. Estimated mean creatinine ratios and differences by bolus volumes were assessed at the time of bolus, and 12, 24, 36, 48 hours. Cox proportional hazard models were used to estimate the association between resolution of AKI and bolus volume after adjustment for confounders. RESULTS We identified 708 eligible encounters with DKA, of which 169 (23.9%) had AKI at presentation and 10 (1.4%) developed AKI after hospitalization. Comparing patients who received low versus high bolus volumes, the proportion of encounters with AKI on presentation was similar (P = 0.364) as was the mean difference in creatinine ratios over time. In adjusted analysis, treatment with high IV fluid bolus volume was only associated with a 6.2% faster resolution of AKI (hazard ratio, 1.062; 95% confidence interval, 0.61-1.87). CONCLUSIONS Intravenous fluid bolus volume was not associated with resolution of AKI in our cohort of children with DKA.
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Affiliation(s)
| | - Morgan Boes
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis
| | | | - M Jennifer Abuzzahab
- Department of Pediatric Endocrinology and McNeely Diabetes Center, Children's Minnesota, St. Paul
| | - David Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
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9
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Hamud AA, Mudawi K, Shamekh A, Kadri A, Powell C, Abdelgadir I. Diabetic ketoacidosis fluid management in children: systematic review and meta-analyses. Arch Dis Child 2022; 107:1023-1028. [PMID: 35738870 DOI: 10.1136/archdischild-2022-324042] [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: 02/25/2022] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
IMPORTANCE Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, which may lead to significant morbidity and mortality. OBJECTIVES To compare the safety and efficacy of liberalised versus conservative intravenous fluid regimens in the management of DKA in children. DATA SOURCE AND STUDY SELECTION Databases from inception to January 2022: MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were included. Only randomised controlled trials (RCTs) that included children aged under 18 years were assessed. Two reviewers performed data assessment and extraction. DATA EXTRACTION AND SYNTHESIS Three studies out of 1536 citations were included. MAIN OUTCOMES The time to the recovery from the DKA; the frequency of paeditric intensive care unit (PICU) admissions; development of brain oedema; reduction in Glasgow Coma Scale (GCS); development of acute kidney injury and all-cause mortality. RESULTS We included three RCTs (n=1457). No evidence of difference was noted in the GCS reduction (risk ratio (RR)=0.77, 95% CI 0.44 to 1.36) or development of brain oedema (RR=0.50, 95% CI 0.15 to 1.68). The time to recovery from DKA was longer in the conservative group (mean difference=1.42, 95% CI 0.28 to 2.56). Time to hospital discharge, adverse or serious adverse events were comparable in the two studied groups. CONCLUSION There is no evidence from this meta-analysis that rate of fluid administration has any effect on adverse neurological and other outcomes or length of hospital stay.
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Affiliation(s)
| | - Khalid Mudawi
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
| | - Ahmed Shamekh
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
| | - Ayodeji Kadri
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
| | - Colin Powell
- Paediatric Emergency Department, Sidra Medicine, Doha, Qatar
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10
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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11
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Long B, Gottlieb M. Liberal versus conservative intravenous fluid administration in pediatric diabetic ketoacidosis. Acad Emerg Med 2022; 29:1399-1400. [PMID: 36164809 DOI: 10.1111/acem.14596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
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12
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Poon SWY, Tung JYL, Wong WHS, Cheung PT, Fu ACC, Pang GSW, To SWY, Wong LM, Wong WY, Chan SY, Yau HC, See WS, But BWM, Wong SMY, Lo PWC, Ng KL, Chan KT, Lam HY, Wong SWC, Lam YY, Yuen HW, Chung JYK, Lee CY, Tay MK, Kwan EYW. Diabetic ketoacidosis in children with new-onset type 1 diabetes mellitus: demographics, risk factors and outcome: an 11 year review in Hong Kong. J Pediatr Endocrinol Metab 2022; 35:1132-1140. [PMID: 36001345 DOI: 10.1515/jpem-2022-0255] [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: 05/11/2022] [Accepted: 08/05/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D). The aim of this study is to analyze the incidence, clinical characteristics, management and outcome of children presenting with DKA in new-onset T1D from 2008 to 2018 in Hong Kong. METHODS Data was extracted from the Hong Kong Childhood Diabetes Registry. All subjects less than 18 years with newly diagnosed T1D from 1 January 2008 to 31 December 2018 managed in the public hospitals were included. Information on demographics, laboratory parameters, DKA-related complications and management were analyzed. RESULTS In the study period, there were 556 children with newly diagnosed T1D in our registry and 43.3% presented with DKA. The crude incidence rate of new-onset T1D with DKA was 1.79 per 100,000 persons/year (CI: 1.56-2.04). Subjects presenting with DKA were younger (9.5 ± 4.5 vs. 10.5 ± 4.4, p=0.01) and had shorter duration of symptoms (4.2 ± 5.9 days vs. 10.6 ± 17.1 days, p<0.01). Regarding management, up to 12.4% were given insulin boluses and 82.6% were started on insulin infusion 1 h after fluid resuscitation. The rate of cerebral edema was 0.8% and there was no mortality. CONCLUSIONS Younger age and shorter duration of symptoms were associated with DKA in new-onset T1D. Despite availability of international guidelines, there was inconsistency in acute DKA management. These call for a need to raise public awareness on childhood diabetes as well as standardization of practice in management of pediatric DKA in Hong Kong.
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Affiliation(s)
- Sarah Wing-Yiu Poon
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, P.R. China
| | - Joanna Yuet-Ling Tung
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, P.R. China
| | - Wilfred Hing-Sang Wong
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, P.R. China
| | - Pik-To Cheung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, P.R. China
| | - Antony Chun-Cheung Fu
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong, P.R. China
| | - Gloria Shir-Wey Pang
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, P.R. China.,Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong, P.R. China
| | - Sharon Wing-Yan To
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong, P.R. China
| | - Lap-Ming Wong
- Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital, Hong Kong, P.R. China
| | - Wai-Yu Wong
- Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital, Hong Kong, P.R. China
| | - Suk-Yan Chan
- Department of Paediatrics, Prince of Wales Hospital, Hong Kong, P.R. China
| | - Ho-Chung Yau
- Department of Paediatrics, Prince of Wales Hospital, Hong Kong, P.R. China
| | - Wing-Shan See
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, P.R. China
| | - Betty Wai-Man But
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong, P.R. China
| | | | - Priscilla Wai-Chee Lo
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong, P.R. China
| | - Kwok-Leung Ng
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong, P.R. China
| | - Kwong-Tat Chan
- Department of Paediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, P.R. China
| | - Hi-Yuet Lam
- Department of Paediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, P.R. China
| | - Sammy Wai-Chun Wong
- Department of Paediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, P.R. China
| | - Yuen-Yu Lam
- Department of Paediatrics, Kwong Wah Hospital, Hong Kong, P.R. China
| | - Hoi-Wing Yuen
- Department of Paediatrics, Kwong Wah Hospital, Hong Kong, P.R. China
| | - Jacky Ying-Ki Chung
- Department of Paediatrics and Adolescent Medicine, Caritas Medical Centre, Hong Kong, P.R. China
| | - Ching-Yee Lee
- Department of Paediatrics and Adolescent Medicine, Caritas Medical Centre, Hong Kong, P.R. China
| | - Ming-Kut Tay
- Department of Paediatrics and Adolescent Medicine, Tseung Kwan O Hospital, Hong Kong, P.R. China
| | - Elaine Yin-Wah Kwan
- Department of Paediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, P.R. China
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13
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Bacha T, Shiferaw Y, Abebaw E. Outcome of diabetic ketoacidosis among paediatric patients managed with modified DKA protocol at Tikur Anbessa specialized hospital and Yekatit 12 hospital, Addis Ababa, Ethiopia. Endocrinol Diabetes Metab 2022; 5:e363. [PMID: 36102127 PMCID: PMC9471591 DOI: 10.1002/edm2.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Tigist Bacha
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesSt Paul Millennium Medical CollegeAddis AbabaEthiopia
| | - Yemisrach Shiferaw
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Ermias Abebaw
- Department of Pediatrics and Child Health, School of MedicineDebre Markos UniversityDebre MarkosEthiopia
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14
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Holder M, Kapellen T, Ziegler R, Bürger-Büsing J, Danne T, Dost A, Holl RW, Holterhus PM, Karges B, Kordonouri O, Lange K, Müller S, Raile K, Schweizer R, von Sengbusch S, Stachow R, Wagner V, Wiegand S, Neu A. Diagnosis, Therapy and Follow-Up of Diabetes Mellitus in Children and Adolescents. Exp Clin Endocrinol Diabetes 2022; 130:S49-S79. [PMID: 35913059 DOI: 10.1055/a-1624-3388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Martin Holder
- Klinikum Stuttgart, Olgahospital, Department of Pediatric Endocrinology and Diabetology, Germany
| | - Thomas Kapellen
- Department of Paediatrics and Adolescent Medicine, University Hospital, Leipzig, Germany
| | - Ralph Ziegler
- Practice for Paediatrics and Adolescent Medicine, Focus on Diabetology, Münster, Germany
| | - Jutta Bürger-Büsing
- Association of Diabetic Children and Adolescents, Diabetes Center, Kaiserslautern, Germany
| | - Thomas Danne
- Children's and Youth Hospital Auf der Bult, Hannover, Germany
| | - Axel Dost
- Department of Paediatrics and Adolescent Medicine, University Hospital Jena, Germany
| | - Reinhard W Holl
- Institute for Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Germany
| | - Paul-Martin Holterhus
- Department of General Paediatrics, University Hospital Schleswig-Holstein, Kiel Campus, Germany
| | - Beate Karges
- Endocrinology and Diabetology Section, University Hospital, RWTH Aachen University, Germany
| | - Olga Kordonouri
- Children's and Youth Hospital Auf der Bult, Hannover, Germany
| | - Karin Lange
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
| | | | - Klemens Raile
- Virchow Hospital, University Medicine, Berlin, Germany
| | - Roland Schweizer
- Department of Pediatrics and Adolescent Medicine, University Hospital Tübingen, Germany
| | - Simone von Sengbusch
- Department of Paediatrics and Adolescent Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Rainer Stachow
- Sylt Specialist Hospital for Children and Adolescents, Westerland, Germany
| | - Verena Wagner
- Joint Practice for Paediatrics and Adolescent Medicine, Rostock, Germany
| | | | - Andreas Neu
- Department of Pediatrics and Adolescent Medicine, University Hospital Tübingen, Germany
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15
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Bergmann KR, Nickel A, Hall M, Cutler G, Abuzzahab MJ, Bretscher B, Lammers S, Watson D, Hester GZ. Association of Neighborhood Resources and Race and Ethnicity With Readmissions for Diabetic Ketoacidosis at US Children's Hospitals. JAMA Netw Open 2022; 5:e2210456. [PMID: 35511179 PMCID: PMC9073568 DOI: 10.1001/jamanetworkopen.2022.10456] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023] Open
Abstract
Importance The Child Opportunity Index 2.0 (COI) assesses neighborhood resources and conditions that influence health. It is unclear whether the COI scores are associated with health outcomes by race and ethnicity among children with type 1 diabetes (T1D). Objective To determine whether COI categories are associated with diabetes-related outcomes by race and ethnicity, including readmissions for diabetic ketoacidosis (DKA) and co-occurring acute kidney injury (AKI) or cerebral edema (CE). Design, Setting, and Participants This cross-sectional study included children discharged with a primary diagnosis of T1D with DKA between January 1, 2009, and December 31, 2018. Merged data were obtained from the Pediatric Health Information System and COI. Participants included children and adolescents younger than 21 years with an encounter for DKA. Data were analyzed from April 29, 2021, to January 5, 2022. Exposures Neighborhood opportunity, measured with the COI as an ordered, categorical score (where a higher score indicates more opportunity), and race and ethnicity. Main Outcomes and Measures The primary outcome was readmission for DKA within 30 and 365 days from an index visit. Secondary outcomes included the proportion of encounters with AKI or CE. Mixed-effects logistic regression was used to generate probabilities of readmission, AKI, and CE for each quintile of COI category by race and ethnicity. Results A total of 72 726 patient encounters were identified, including 38 924 (53.5%) for girls; the median patient age was 13 (IQR, 9-15) years. In terms of race and ethnicity, 600 (0.8%) of the encounters occurred in Asian patients, 9969 (13.7%) occurred in Hispanic patients, 16 876 (23.2%) occurred in non-Hispanic Black (hereinafter Black) patients, 40 129 (55.2%) occurred in non-Hispanic White (hereinafter White) patients, and 5152 (7.1%) occurred in patients of other race or ethnicity. The probability of readmission within 365 days was significantly higher among Black children with a very low COI category compared with Hispanic children (risk difference, 7.8 [95% CI, 6.0-9.6] percentage points) and White children (risk difference, 7.5 [95% CI, 5.9-9.1] percentage points) at the same COI category. Similar differences were seen for children with very high COI scores and across racial groups. The COI category was not associated with AKI or CE. However, race and ethnicity constituted a significant factor associated with AKI across all COI categories. The probability of AKI was 6.8% among Black children compared with 4.2% among Hispanic children (risk difference, 2.5 [95% CI, 1.7-3.3] percentage points) and 4.8% among White children (risk difference, 2.0 [95% CI, 1.3-2.6] percentage points). Conclusions and Relevance These results suggest that Black children with T1D experience disparities in health outcomes compared with other racial and ethnic groups with similar COI categories. Measures to prevent readmissions for DKA should include interventions that target racial disparities and community factors.
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Affiliation(s)
- Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Amanda Nickel
- Department of Research and Sponsored Programs, Children’s Minnesota, Minneapolis
| | - Matt Hall
- Department of Analytics, Children’s Hospital Association, Overland Park, Kansas
| | - Gretchen Cutler
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | - Brianna Bretscher
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Dave Watson
- Department of Research and Sponsored Programs, Children’s Minnesota, Minneapolis
| | - Gabrielle Z. Hester
- Department of Value and Clinical Excellence, Children’s Minnesota, Minneapolis
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16
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Abstract
Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.
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17
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Maurice L, Julliand S, Polak M, Bismuth E, Storey C, Renolleau S, Dauger S, Le Bourgeois F. Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols. Eur J Pediatr 2022; 181:1497-1506. [PMID: 34993625 DOI: 10.1007/s00431-021-04332-4] [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: 08/06/2021] [Revised: 10/24/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
UNLABELLED The best protocol for severe inaugural diabetic ketoacidosis (DKA) in children remains unclear. We compared two protocols by assessing effects during the first 24 h on osmolality, serum sodium, and glucose variations, which are associated with the risk of cerebral oedema, the most dreaded complication of DKA. We also recorded complications. We retrospectively included children aged 28 days to 18 years and admitted for severe DKA to either of two paediatric intensive care units (PICUs) in Paris (France). The two protocols differed regarding hydration volume, glucose intake, and sodium intake. From 17 June 2010 to 17 June 2015, 93 patients were included, 29 at one PICU, and 64 at the other. We compared severe glycaemic drops (> 5.5 mmol/L/h), mean glycaemia variations, serum sodium, serum osmolality, and the occurrence of cerebral oedema (CE) during the first 24 h after PICU admission. Severe glycaemic drops occurred in 70% of patients, with no between-group difference. Blood glucose, serum sodium, and serum osmolality variations were comparable. Seven (7.5%) patients were treated for suspected CE, (4 [10.3%)] and 3 [6.3%]) in each PICU; none had major residual impairments. CONCLUSION The two paediatric DKA-management protocols differing in terms of fluid-volume, glucose, and sodium intakes had comparable effects on clinical and laboratory-test changes within 24 h. Major drops in glycaemia and osmolality were common with both protocols. No patients had residual neurological impairments. WHAT IS KNOWN • Cerebral oedema is the most severe complication of diabteic ketoacidosis in children.The risk of cerebral oedema is dependant on both patient related and treatment-related factors. • The optimal protocol for managing severe inaugural diabetic ketoacidosis in children remains unclear, and few studies have targeted this specific population. WHAT IS NEW • Two management protocols that complied with ISPAD guidelines but differed regarding the amounts of fluids, glucose, and sodium administered produced similar outcomes in children with severe inaugural diabetic ketoacidosis. • Cerebral oedema was rare with both protocols and caused no lasting impairments.
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Affiliation(s)
- Laure Maurice
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Sébastien Julliand
- Paediatric Mobile Emergency Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Michel Polak
- Department of Paediatric Endocrinology, Gynaecology, and Diabetology, IMAGINE Affiliate, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Elise Bismuth
- Department of Paediatric Endocrinology and Diabetology, Robert Debré Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Storey
- Department of Paediatric Endocrinology and Diabetology, Robert Debré Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sylvain Renolleau
- Paediatric Intensive Care Unit, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Stéphane Dauger
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Fleur Le Bourgeois
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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18
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Grout S, Maue D, Berrens Z, Swinger N, Malin S. Diabetic Ketoacidosis With Refractory Hypokalemia Leading to Cardiac Arrest. Cureus 2022; 14:e23439. [PMID: 35494963 PMCID: PMC9038207 DOI: 10.7759/cureus.23439] [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] [Accepted: 03/24/2022] [Indexed: 11/16/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is known to cause total body potassium depletion, but during initial presentation, very few patients are hypokalemic, and even fewer patients experience clinical effects. As the correction of acidosis and insulin drive potassium intracellularly, measured serum potassium levels decrease and require repletion. This phenomenon is well described, and severe hypokalemia necessitates delaying insulin therapy. Less well described is the kaliuretic nature of treatments of cerebral edema. We present a case of an adolescent male with new-onset type 2 diabetes who presented in DKA with signs of cerebral edema, hyperosmolarity, and hypokalemia. As insulin and cerebral edema therapy were initiated, his hypokalemia worsened despite significant IV repletion, eventually leading to ventricular tachycardia and cardiac arrest. Over the following 36 hours, the patient received >590 milliequivalents (mEq) of potassium. He was discharged home 12 days after admission without sequelae of his cardiac arrest.
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19
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Zheng DJ, Iskander S, Vujcic B, Amin K, Valani R, Yan JW. A comparison of adult diabetic ketoacidosis treatment protocols from Canadian emergency departments. Can J Diabetes 2021; 46:269-276.e2. [DOI: 10.1016/j.jcjd.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/05/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
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20
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Rewers A, Kuppermann N, Stoner MJ, Garro A, Bennett JE, Quayle KS, Schunk JE, Myers SR, McManemy JK, Nigrovic LE, Trainor JL, Tzimenatos L, Kwok MY, Brown KM, Olsen CS, Casper TC, Ghetti S, Glaser NS. Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children With Diabetic Ketoacidosis. Diabetes Care 2021; 44:2061-2068. [PMID: 34187840 PMCID: PMC8740930 DOI: 10.2337/dc20-3113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/20/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment. RESEARCH DESIGN AND METHODS The current analysis involved moderate or severe DKA episodes (n = 714) in children age <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial. Children were assigned to one of four treatment groups using a 2 × 2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration). RESULTS The rate of change of pH did not differ by treatment arm, but Pco2 increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%). CONCLUSIONS In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco2 than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.
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Affiliation(s)
- Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento.,Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
| | - Michael J Stoner
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jeffrey E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Simona Ghetti
- Department of Psychology and the Center for Mind and Brain, University of California, Davis, Davis, CA
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
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21
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Wright N, Thomas R. BSPED guideline: what we know and why the guideline was changed. Arch Dis Child Educ Pract Ed 2021; 106:226-228. [PMID: 33658290 DOI: 10.1136/archdischild-2020-320077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Neil Wright
- Paediatric Endocrinology and Diabetes, Sheffield Children's Hospital, Sheffield, UK
| | - Rum Thomas
- Paediatric Intensive Care Unit, Sheffield Children's Hospital, Sheffield, South Yorkshire, UK
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22
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Agwu JC, Ng SM. Fluid and electrolyte therapy in childhood diabetic ketoacidosis management: A rationale for new national guideline. Diabet Med 2021; 38:e14595. [PMID: 33963601 DOI: 10.1111/dme.14595] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/04/2021] [Indexed: 12/13/2022]
Abstract
Fluid and electrolyte therapy in childhood diabetic ketoacidosis (DKA) management has been controversial. Previous National Institute for Health and Care Excellence (NICE) 2015 guidance advocated a restricted fluid regimen while more recent guidelines have advocated a more liberal approach to fluid replacement in DKA. At the core of the debate is the need to avoid developing cerebral oedema as a complication. Although subtle asymptomatic cerebral oedema is common in children presenting in DKA, clinically apparent cerebral oedema is rare and has been reported in approximately 0.5%-1% of DKA cases in children. Recent research evidence has shown that there was no clear evidence of a difference in rates of clinically apparent cerebral injury in children in DKA managed with a range of fluid volumes and rates of rehydration. In view of this, NICE has updated its guideline. In this paper, we review literature evidence underpinning the current understanding of the pathophysiology of cerebral oedema in children and discuss the rationale for the new NICE guidance.
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Affiliation(s)
- Juliana Chizo Agwu
- Department of Paediatrics, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Institute of Clinical Sciences, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sze M Ng
- Paediatric Department, Southport and Ormskirk NHS Trust, Ormskirk, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Diagnostik, Therapie und Verlaufskontrolle des Diabetes mellitus im Kindes- und Jugendalter. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00769-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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24
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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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25
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Bergmann KR, Abuzzahab MJ, Nowak J, Arms J, Cutler G, Christensen E, Finch M, Kharbanda A. Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis. Pediatr Emerg Care 2021; 37:e236-e242. [PMID: 30020245 DOI: 10.1097/pec.0000000000001550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aims of this study were to describe the use of Ringer's lactate (LR) or normal saline (NS) for resuscitation among children with diabetic ketoacidosis (DKA) and compare the effect of fluid type on cost, length of stay, and rate of cerebral edema (CE). METHODS This is a retrospective study of 49,737 children aged 0 to 17 years with DKA between January 1, 2005, and September 30, 2015, using data from the Pediatric Health Information System. Treatment with LR or NS was identified. Our primary outcomes were total adjusted cost and length of stay. Our secondary outcome was CE rate per 1000 episodes. RESULTS The majority of patients were treated with NS (n = 43,841 [88%]) compared with LR (n = 1762 [4%]) or both NS and LR (n = 4134 [8%]). Hospital-year-specific practice patterns were used to investigate the effect of fluid type across resuscitation fluid groups. Total adjusted cost was $1160 less (95% confidence interval, -1468 to -852), or -14.2%, for cases with any episode of LR compared with NS only. Length of stay was not different across groups. The rate of cerebral edema per 1000 episodes was 12.7 for cases with any episode of LR compared with 34.6 NS only (difference, -21.9; 95% confidence interval, -30.4 to -13.3). CONCLUSIONS Ringer's lactate was infrequently used for resuscitation of pediatric DKA patients. However, resuscitation with LR compared with NS was associated with lower total cost and rates of CE. Further investigation using patient-level clinical and laboratory data is needed to evaluate factors that drive cost and risk of CE development with each fluid.
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Affiliation(s)
- Kelly R Bergmann
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
| | - M Jennifer Abuzzahab
- Department of Pediatric Endocrinology and McNeely Diabetes Center, Children's Hospitals and Clinics of Minnesota, St Paul
| | | | - Joe Arms
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
| | - Gretchen Cutler
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
| | - Eric Christensen
- Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Mike Finch
- Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Anupam Kharbanda
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
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Thawer Z, Gregoire K, Coo H, Saleh DS. Variability in Emergency Management of Pediatric Diabetic Ketoacidosis. Can J Diabetes 2021; 45:757-760. [PMID: 34112617 DOI: 10.1016/j.jcjd.2021.03.003] [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: 12/26/2020] [Revised: 02/27/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Our aim in this study was to identify pediatric patients presenting in diabetic ketoacidosis (DKA) who received initial treatment inconsistent with current guidelines, and then to track associated complications. METHODS This retrospective chart review examined 47 pediatric patients admitted to our institution with DKA, including those transferred from community hospitals. Primary outcome measures were exposure to treatment-related risk factors for cerebral edema (CE), including administration of an intravenous (IV) insulin bolus, IV bicarbonate, insulin within 1 hour of IV fluid start and non-NPO (nil per os) status. RESULTS Seventy-five percent of patients were exposed to at least one management practice that deviated from guidelines. Thirty-four percent of patients were exposed to a treatment-related risk factor for CE, with a significantly higher prevalence in those presenting to community centres (52% vs 19%; p=0.02). There were no radiologically confirmed cases of CE. CONCLUSIONS Despite the presence of multiple, evidence-based guidelines, a significant proportion of children---and especially those who present to community centres---are exposed to practices that increase CE risk.
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Affiliation(s)
- Zoyah Thawer
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada; Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
| | - Keith Gregoire
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
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Azova S, Rapaport R, Wolfsdorf J. Brain injury in children with diabetic ketoacidosis: Review of the literature and a proposed pathophysiologic pathway for the development of cerebral edema. Pediatr Diabetes 2021; 22:148-160. [PMID: 33197066 PMCID: PMC10127934 DOI: 10.1111/pedi.13152] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/06/2020] [Accepted: 10/29/2020] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Svetlana Azova
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert Rapaport
- Division of Pediatric Endocrinology and Diabetes, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joseph Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Redant S, De Bels D, Massaut J, Devriendt J, Beretta-Piccoli X, Attou R, Honore PM. Ketoacidosis in type 1 diabetics: we should return to pediatric guidelines. Ann Intensive Care 2020; 10:19. [PMID: 32048069 PMCID: PMC7013019 DOI: 10.1186/s13613-020-0639-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/04/2020] [Indexed: 11/17/2022] Open
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Myers SR, Glaser NS, Trainor JL, Nigrovic LE, Garro A, Tzimenatos L, Quayle KS, Kwok MY, Rewers A, Stoner MJ, Schunk JE, McManemy JK, Brown KM, DePiero AD, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes. JAMA Netw Open 2020; 3:e2025481. [PMID: 33275152 PMCID: PMC7718599 DOI: 10.1001/jamanetworkopen.2020.25481] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Acute kidney injury (AKI) occurs commonly during diabetic ketoacidosis (DKA) in children, but the underlying mechanisms and associations are unclear. OBJECTIVE To investigate risk factors for AKI and its association with neurocognitive outcomes in pediatric DKA. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a prospective, multicenter, randomized clinical trial comparing fluid protocols for pediatric DKA in 13 US hospitals. Included DKA episodes occurred among children age younger than 18 years with blood glucose 300 mg/dL or greater and venous pH less than 7.25 or serum bicarbonate level less than 15 mEq/L. EXPOSURES DKA requiring intravenous insulin therapy. MAIN OUTCOMES AND MEASURES AKI occurrence and stage were assessed using serum creatinine measurements using Kidney Disease: Improving Global Outcomes criteria. DKA episodes with and without AKI were compared using univariable and multivariable methods, exploring associated factors. RESULTS Among 1359 DKA episodes (mean [SD] patient age, 11.6 [4.1] years; 727 [53.5%] girls; 651 patients [47.9%] with new-onset diabetes), AKI occurred in 584 episodes (43%; 95% CI, 40%-46%). A total of 252 AKI events (43%; 95% CI, 39%-47%) were stage 2 or 3. Multivariable analyses identified older age (adjusted odds ratio [AOR] per 1 year, 1.05; 95% CI, 1.00-1.09; P = .03), higher initial serum urea nitrogen (AOR per 1 mg/dL increase, 1.14; 95% CI, 1.11-1.18; P < .001), higher heart rate (AOR for 1-SD increase in z-score, 1.20; 95% CI, 1.09-1.32; P < .001), higher glucose-corrected sodium (AOR per 1 mEq/L increase, 1.03; 95% CI, 1.00-1.06; P = .001) and glucose concentrations (AOR per 100 mg/dL increase, 1.19; 95% CI, 1.07-1.32; P = .001), and lower pH (AOR per 0.1 increase, 0.63; 95% CI, 0.51-0.78; P < .001) as variables associated with AKI. Children with AKI, compared with those without, had lower scores on tests of short-term memory during DKA (mean [SD] digit span recall: 6.8 [2.4] vs 7.6 [2.2]; P = .02) and lower mean (SD) IQ scores 3 to 6 months after recovery from DKA (100.0 [12.2] vs 103.5 [13.2]; P = .005). Differences persisted after adjusting for DKA severity and demographic factors, including socioeconomic status. CONCLUSIONS AND RELEVANCE These findings suggest that AKI may occur more frequently in children with greater acidosis and circulatory volume depletion during DKA and may be part of a pattern of multiple organ injury involving the kidneys and brain.
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Affiliation(s)
- Sage R. Myers
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole S. Glaser
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jennifer L. Trainor
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Aris Garro
- Department of Emergency Medicine, Rhode Island Hospital, Providence
- Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Kimberly S. Quayle
- Division of Emergency Medicine, St Louis Children’s Hospital, St Louis, Missouri
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Maria Y. Kwok
- Division of Emergency Medicine, NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Arleta Rewers
- Division of Emergency Medicine, Colorado Children’s Hospital, Denver
- Department of Pediatrics, University of Colorado–Denver School of Medicine, Aurora
| | - Michael J. Stoner
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Jeff E. Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Julie K. McManemy
- Division of Emergency Medicine, Texas Children’s Hospital, Houston
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kathleen M. Brown
- Division of Emergency Medicine, Children’s National Medical Center, Washington, District of Columbia
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrew D. DePiero
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Simona Ghetti
- Department of Psychology, UC Davis Health, University of California School of Medicine, Sacramento
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
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Immunoglobulins reduced oxidative stress in human microglial cells induced by high dose of acetoacetate. Brain Res 2020; 1748:147054. [PMID: 32818529 DOI: 10.1016/j.brainres.2020.147054] [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: 02/21/2020] [Revised: 07/12/2020] [Accepted: 08/08/2020] [Indexed: 11/23/2022]
Abstract
Diabetic ketoacidosis (DKA) has been associated with cognitive impairment and structural alterations in the brain. There is increased evidence supporting the role of neuroinflammation in causing these alterations. In the present study, using human microglial cell line (CHME-5), we aimed to investigate the effect of immunoglobulins (IG) on survival, activation, reactive oxygen species (ROS) and cytokine production of microglia exposed to ketone bodies. We demonstrated that high and low dose of ketone bodies induced a significant increase in ROS within 1 h after exposure to CHME-5 cells with upregulation in mitochondrial superoxide level 5 min after exposure suggestive of early and selective impairment of mitochondrial function. A significant and delayed increase of apoptosis of CHME-5 cells was observed 4 days after ketone bodies exposure. Cytokine expression reached a peak within 1 h and persisted for 3 days after exposure to ketone bodies. IG significantly reduced ROS and transiently suppressed cytokine expression of CHME-5 cells after exposure to ketone bodies. However, no effect of IG on apoptosis was observed. Overall, these results supported that ketone bodies induced microglia activation with early and selective impairment of mitochondrial function, increased cytokines expression and delayed increase in apoptosis. IG suppressed microglia activation and transiently inhibited cytokines expression without affecting apoptosis. These results warrant further experimental work on the role of microglia and potential benefit of IG in brain structural changes induced by DKA.
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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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Wright N, Thomas R. Response to: Management of fluids in paediatric diabetic ketoacidosis: concerns over new guidance. Arch Dis Child 2020; 105:1020-1021. [PMID: 32747374 DOI: 10.1136/archdischild-2020-319746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Neil Wright
- Paediatric Endocrinology and Diabetes, Sheffield Children's Hospital, Sheffield, UK
| | - Rum Thomas
- Paediatric Intensive Care Unit, Sheffield Children's Hospital, Sheffield, UK
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Tasker RC. Fluid management during diabetic ketoacidosis in children: guidelines, consensus, recommendations and clinical judgement. Arch Dis Child 2020; 105:917-918. [PMID: 32847796 DOI: 10.1136/archdischild-2020-320164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Robert Charles Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Selwyn College, University of Cambridge, Cambridge, UK
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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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Lapolla A, Amaro F, Bruttomesso D, Di Bartolo P, Grassi G, Maffeis C, Purrello F, Tumini S. Diabetic ketoacidosis: A consensus statement of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology and Pediatric Diabetoloy (SIEDP). Nutr Metab Cardiovasc Dis 2020; 30:1633-1644. [PMID: 32771260 DOI: 10.1016/j.numecd.2020.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Diabetic ketoacidosis (DKA) is a serious medical emergency once considered typical of type 1 diabetes (T1DM), but now reported to occur in type 2 and GDM patients as well. DKA can cause severe complications and even prove fatal. The aim of our study was to review recent international and national guidelines on diagnosis, clinical presentation and treatment of diabetic ketoacidosis, to provide practical clinical recommendations. METHODS AND RESULTS Electronic databases (MEDLINE (via PUB Med), Scopus, Cochrane library were searched for relevant literature. Most international and national guidelines indicate the same accurate flow chart to diagnose, to evaluate from clinical and laboratory point of view, and treat diabetic ketoacidosis. CONCLUSION Prompt diagnosis, rapid execution of laboratory analysis and correct treatment are imperative to reduce the mortality related to diabetic ketoacidosis. These recommendations are designed to help healthcare professionals reduce the frequency and burden of DKA.
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Affiliation(s)
| | - Flavia Amaro
- Department of Pediatrics University of Chieti, Chieti, Italy
| | | | - Paolo Di Bartolo
- Ravenna Diabetes Clinic, Romagna Diabetes Network, Internal DPT of Romagna Local Health Autorithy, Italy; Chief Italian Association of Diabetologists (AMD), Rome, Italy
| | - Giorgio Grassi
- Endocrinology, Diabetology and Metabolic Unit, City of Health and Science Torino, Italy
| | - Claudio Maffeis
- Chief Italian Society of Pediatric Endocrinology and Diabetology (SIEDP), Torino, Italy; Chief Pediatric Diabetes and Metabolic Disorder Unit, University Hospital, Verona, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania Catania, Italy; Chief Italian Diabetes Society (SID), Rome, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, Chieti, Italy
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Castellanos L, Tuffaha M, Koren D, Levitsky LL. Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus. Paediatr Drugs 2020; 22:357-367. [PMID: 32449138 DOI: 10.1007/s40272-020-00397-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.
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Affiliation(s)
- Luz Castellanos
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Marwa Tuffaha
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Dorit Koren
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA.
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Valero-Guzmán L, Vásquez-Hoyos P, Camacho-Cruz J, Maya-Hijuelos LC, Martínez-Lozada S, Rubiano-Acevedo AM, Lara-Bernal M, Diaz-Angarita T. Difference in the duration of pediatric diabetic ketoacidosis: Comparison of new-onset to known type 1 diabetes. Pediatr Diabetes 2020; 21:791-799. [PMID: 32181961 DOI: 10.1111/pedi.13007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 01/23/2020] [Accepted: 03/12/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To compare the duration (hours until HCO3- ≥ 15 mmol/L) of diabetic ketoacidosis (DKA) episodes that are the first manifestation of new type 1 diabetes (NT1D) and those that are a complication in patients with previously diagnosed type 1 diabetes (PT1D). METHODS A multicenter retrospective cohort study was designed. The duration of DKA was measured from the start of the treatment. The primary outcome was the comparison of the time needed in each group to reach HCO3- ≥ 15 mmol/L. The secondary outcomes were the comparison of the time to reach pH ≥ 7.3 and length of hospital stay in each group. Data were analyzed with a bivariate analysis of the variables vs primary outcome. Then, a regression model was analyzed. Results There were 305 episodes included (NT1D: 115, PT1D: 190). DKA in the NT1D group lasted longer (NT1D 20 (16-19) vs PT1D 12 (8-16), hours, P < .01) with a significant difference in each level of DKA severity. This group also took longer to reach pH ≥ 7.3 (NT1D 16 (12-22) vs PT1D 9 (6-12), hours, P < .01) and had a longer hospital stay (NT1D 9 (6-12) vs PT1D 7 (4-10), hours, P < .01). CONCLUSION The duration of DKA is longer in patients with NT1D regardless of characteristics like DKA severity, duration of symptoms, and type of treatments received.
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Affiliation(s)
- Leonardo Valero-Guzmán
- Department of Pediatrics, Universidad Nacional de Colombia, Fundación Hospital de la Misericordia, Bogotá, Colombia
| | - Pablo Vásquez-Hoyos
- Department of Pediatrics, Universidad Nacional de Colombia, Fundación Universitaria de Ciencias de la Salud, Hospital de San José, Bogotá, Colombia
| | - Jhon Camacho-Cruz
- Department of Pediatrics, Fundación Universitaria Sanitas, Clínica Universitaria Colombia, Fundación Universitaria de Ciencias de la Salud, Hospital de San José, Bogotá, Colombia
| | - Luis Carlos Maya-Hijuelos
- Department of Pediatrics, Universidad Nacional de Colombia, UCIKids, Hospital Infantil Rafael Henao Toro, Manizales, Colombia
| | - Susan Martínez-Lozada
- Department of Pediatrics, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | | | - Marleny Lara-Bernal
- Department of Pediatrics, Universidad del Rosario, Clínica Infantil Colsubsidio, Bogotá, Colombia
| | - Tomas Diaz-Angarita
- Department of Pediatrics, Fundación Universitaria de Ciencias de la Salud, Hospital Universitario Infantil de San José, Bogotá, Colombia
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Abstract
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, CA, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Bergmann KR, Abuzzahab MJ, Arms J, Cutler G, Vander Velden H, Simper T, Christensen E, Watson D, Kharbanda A. A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis. Pediatrics 2020; 145:peds.2019-1104. [PMID: 32054821 DOI: 10.1542/peds.2019-1104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness. METHODS We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes. RESULTS We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; P = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized. CONCLUSIONS Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.
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Affiliation(s)
| | - M Jennifer Abuzzahab
- Pediatric Endocrinology and McNeely Diabetes Center, Children's Minnesota, St Paul, Minnesota; and
| | - Joe Arms
- Departments of Emergency Medicine
| | | | | | | | - Eric Christensen
- College of Continuing and Professional Studies, University of Minnesota, Minneapolis, Minnesota
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40
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Mencher SR, Frank G, Fishbein J. Diabetic Ketoacidosis at Onset of Type 1 Diabetes: Rates and Risk Factors Today to 15 Years Ago. Glob Pediatr Health 2019; 6:2333794X19870394. [PMID: 31453269 PMCID: PMC6696834 DOI: 10.1177/2333794x19870394] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/03/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is a serious, potentially lethal complication of type 1 diabetes mellitus that may be present at diagnosis. The aim of this study was to determine factors associated with presentation in DKA in new-onset youth and compare the rate of DKA and risk factors to a similar study 15 years prior. This study was a retrospective chart review of newly diagnosed patients with type 1 diabetes mellitus from 2010 to 2013. Of the 276 patients, 29% presented in DKA, compared with 38% 15 years prior (P < .002). Those with Medicaid, those misdiagnosed at initial encounter, and those not evaluated by a pediatrician initially were more likely to present in DKA (P = .002, P = .002, P < .001, respectively). The diagnosis of diabetes was not elicited in one third of patients who ultimately presented in DKA. Pediatricians should be reeducated to ask about polyuria and polydipsia in routine encounters. Furthermore, public awareness initiatives are needed to reduce late presentation in DKA.
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Affiliation(s)
| | - Graeme Frank
- Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Joanna Fishbein
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
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Glackin S, Metzger D, Hanas R, Chanoine JP. Is Age a Risk Factor for Cerebral Edema in Children With Diabetic Ketoacidosis? A Literature Review. Can J Diabetes 2019; 44:111-118. [PMID: 31311730 DOI: 10.1016/j.jcjd.2019.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 03/25/2019] [Accepted: 04/30/2019] [Indexed: 12/16/2022]
Abstract
Cerebral edema (CE) is a rare but potentially fatal complication of diabetic ketoacidosis (DKA) in children with type 1 diabetes. CE is frequently mentioned as being more common in young children. The primary objective of this study was to review the evidence suggesting that younger age is a risk factor for the development of CE during DKA. The secondary objective was to assess if younger children are at a higher risk of DKA and severe DKA. A literature review was performed, and studies which reported the frequency of CE, DKA and severe DKA in children <3 and 3 to 5 years of age were included. Among the 6 studies reporting the frequency of CE that were identified, 5 good-quality studies found no significant association between younger age and higher risk of CE. Twenty-seven studies (DKA frequency: 11.3% to 54%) reported DKA frequency as a function of age. Most published studies found a higher frequency of DKA in children <5 years of age (20/25 studies), and in particular in those in the first 2 to 3 years of life (8/8 studies). There was inconclusive evidence to determine whether the severity of DKA was influenced by age. In conclusion, the commonly held view that CE is more common in younger children is not supported by the existing literature. Published data suggest that DKA (and possibly severe DKA) is more common in very young children. Regardless of age, all children with DKA should be monitored carefully for the development of CE.
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Affiliation(s)
- Sinead Glackin
- Endocrinology & Diabetes Unit, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
| | - Daniel Metzger
- Endocrinology & Diabetes Unit, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jean-Pierre Chanoine
- Endocrinology & Diabetes Unit, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
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42
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Glaser N, Kuppermann N. Fluid treatment for children with diabetic ketoacidosis: How do the results of the pediatric emergency care applied research network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (FLUID) Trial change our perspective? Pediatr Diabetes 2019; 20:10-14. [PMID: 30417497 DOI: 10.1111/pedi.12795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/03/2018] [Indexed: 01/08/2023] Open
Abstract
The optimal fluid treatment protocol for children with diabetic ketoacidosis (DKA) has long been a subject of controversy. Until recently, there was no high-quality evidence from randomized clinical trials to support an optimal guideline, and recommendations were mainly based on theoretical considerations. As a consequence, fluid treatment protocols for children with DKA vary between institutions (and countries). In June 2018, the results from the Fluid Therapies Under Investigation in DKA Trial conducted in the Pediatric Emergency Care Applied Research Network were published. This large, factorial-designed randomized controlled trial assessed neurological outcomes of 1387 children with DKA who were treated with one of four fluid protocols that varied in infusion rate and sodium content. In this commentary, we review and discuss the results of this new study and the implications for clinical care of DKA in children.
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Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, California
| | - Nathan Kuppermann
- Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, California.,Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, California
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43
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Jayashree M, Williams V, Iyer R. Fluid Therapy For Pediatric Patients With Diabetic Ketoacidosis: Current Perspectives. Diabetes Metab Syndr Obes 2019; 12:2355-2361. [PMID: 31814748 PMCID: PMC6858801 DOI: 10.2147/dmso.s194944] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/24/2019] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Muralidharan Jayashree
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Correspondence: Muralidharan Jayashree Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, IndiaTel +91 172 275 5311Fax +91-172-2744401 Email
| | - Vijai Williams
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajalakshmi Iyer
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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44
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Shah RA. QUESTION 2: Do conservative rates of rehydration in children with diabetic ketoacidosis decrease the risk of cerebral oedema? Arch Dis Child 2018; 103:1180-1183. [PMID: 30282624 DOI: 10.1136/archdischild-2018-315956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/04/2018] [Accepted: 09/05/2018] [Indexed: 11/04/2022]
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45
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 344] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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46
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Vukovic R, Jesic MD, Vorgucin I, Stankovic S, Folic N, Milenkovic T, Sajic S, Katanic D, Zivic S, Markovic S, Soldatovic I. First report on the nationwide incidence of type 1 diabetes and ketoacidosis at onset in children in Serbia: a multicenter study. Eur J Pediatr 2018; 177:1155-1162. [PMID: 29774417 DOI: 10.1007/s00431-018-3172-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/05/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
Abstract
UNLABELLED Data regarding incidence of type 1 diabetes (T1DM), as well as data on frequency and severity of diabetic ketoacidosis (DKA) at the time of T1DM diagnosis is of paramount importance for national and regional healthcare planning. The aim of present multicenter study was to provide the first report regarding nationwide annual incidence rates for T1DM in youth in Serbia, as well as prevalence of DKA at the time of diagnosis. Data on all pediatric patients with newly diagnosed T1DM was retrospectively collected from all 15 regional centers for pediatric diabetes in Serbia during the period 2007-2017. During the study period, average-standardized incidence of T1DM in youth < 19 years was 11.82/100,000, and 14.28/100,000 in 0-14 years age group, with an average yearly increase in incidence of 5.9%. High prevalence of DKA (35.1%) at the time of diagnosis was observed, with highest frequency in children aged < 5 years (47.2%). CONCLUSION This is the first study reporting the nationwide incidence of T1DM and alarmingly high prevalence of DKA at diagnosis in youth in Serbia. The focus of public health preventive measures should be directed towards the preschoolers, considering the highest frequency and severity of DKA observed in this age group. What is Known: • Knowing regional T1DM incidence is of paramount importance for resource allocation and healthcare services provision. • DKA is the leading cause of acute mortality in youth with T1DM, and public health preventive educational measures could improve early diagnosis and reduce the frequency and severity of DKA at presentation. What is New: • Incidence of pediatric T1DM in Serbia is on the rise, with an average yearly increase of 5.9%. • Worryingly high prevalence of DKA (35.1%) at the time of T1DM diagnosis was observed, with the highest frequency of DKA in children aged < 5 years (47.2%).
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Affiliation(s)
- Rade Vukovic
- Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, Belgrade, 11070, Serbia.
| | - Maja D Jesic
- University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia.,School of Medicine, University of Belgrade, Dr Subotica 15, Belgrade, 11000, Serbia
| | - Ivana Vorgucin
- Institute for Children and Youth Health Care of Vojvodina, Hajduk Veljkova 10, Novi Sad, 21000, Serbia.,Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
| | - Sandra Stankovic
- Children Clinic, Clinical Center Nis, Dr Zorana Djindjica Blvd. 48a, Nis, 18000, Serbia
| | - Nevena Folic
- Pediatric Clinic, Clinical Centre Kragujevac, Zmaj Jovina 30, Kragujevac, 34000, Serbia.,Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
| | - Tatjana Milenkovic
- Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, Belgrade, 11070, Serbia
| | - Silvija Sajic
- University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia.,School of Medicine, University of Belgrade, Dr Subotica 15, Belgrade, 11000, Serbia
| | - Dragan Katanic
- Institute for Children and Youth Health Care of Vojvodina, Hajduk Veljkova 10, Novi Sad, 21000, Serbia.,Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
| | - Sasa Zivic
- Children Clinic, Clinical Center Nis, Dr Zorana Djindjica Blvd. 48a, Nis, 18000, Serbia.,Faculty of Medicine, University of Nis, Dr Zorana Djindjica Blvd. 81, Nis, 18000, Serbia
| | - Slavica Markovic
- Pediatric Clinic, Clinical Centre Kragujevac, Zmaj Jovina 30, Kragujevac, 34000, Serbia.,Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
| | - Ivan Soldatovic
- Institute for Medical Statistics and Informatics, School of Medicine, University of Belgrade, Dr Subotica 15, Belgrade, 11000, Serbia
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Central Pontine Myelinolysis in Pediatric Diabetic Ketoacidosis. Case Rep Crit Care 2018; 2018:4273971. [PMID: 29973999 PMCID: PMC6008881 DOI: 10.1155/2018/4273971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 04/18/2018] [Indexed: 01/24/2023] Open
Abstract
Central pontine myelinolysis (CPM) is rarely reported in pediatric patients with diabetic ketoacidosis (DKA). We report this case of a 16-year-old female with new onset diabetes presenting with DKA, who received aggressive fluid resuscitation and sodium bicarbonate in the emergency department. Later she developed altered mental status concerning for cerebral edema and received hyperosmolar therapy with only transient improvement. Soon she became apneic requiring emergent endotracheal intubation. MRI brain showed cerebral edema, CPM, and subdural hemorrhage. She was extubated on day seven and exhibited mild dysmetria, ataxia, unilateral weakness, and neglect. Upon discharge she was able to ambulate with a walker and speak and eat without difficulty. Although less common than cerebral edema, CPM should be considered in DKA patients with acute neurologic deterioration. Fluid and bicarbonate therapy should be individualized, but larger studies would help guide the management. Although poor outcomes are reported in CPM, favorable outcomes are possible.
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48
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Wherrett DK, Ho J, Huot C, Legault L, Nakhla M, Rosolowsky E. Type 1 Diabetes in Children and Adolescents. Can J Diabetes 2018; 42 Suppl 1:S234-S246. [DOI: 10.1016/j.jcjd.2017.10.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments. CAN J EMERG MED 2018; 17:656-61. [PMID: 26461431 DOI: 10.1017/cem.2015.56] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Diabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences. METHODS Pediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema. RESULTS Responses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5-20 mL/kg) and length of time boluses should be administered (20-120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration. CONCLUSIONS This is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.
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50
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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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