Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children With Diabetic Ketoacidosis

Effects of insulin infusion volume on diabetic ketoacidosis outcome in pediatrics: Retrospective observational study

Diabetic ketoacidosis (DKA) poses a significant risk to diabetic pediatric patients, warranting effective management strategies to prevent complications. Current DKA management protocols often use normal saline for insulin infusion, which can contribute to hyperchloremia. This study aimed to compare the effects of 2 insulin concentrations (1 unit of regular human insulin per 1 mL vs 1 unit per 10 mL of 0.9% sodium chloride) on the incidence of hyperchloremic metabolic acidosis (HMA). A retrospective observational study was conducted on pediatric patients admitted to a large pediatric hospital, recognized as a leading provider of tertiary pediatric care in the region, from January 2018 to June 2023. The study compared preprotocol (1 unit/10 mL) and postprotocol (1 unit/1 mL) insulin concentrations. Data collected included demographics, DKA severity, electrolytes, intravenous fluid type, total volume, chloride load, and length of hospital stay. The study included 279 DKA admissions, with 140 preprotocol and 139 postprotocol cases. The postprotocol group had a higher incidence of new onset of type 1 diabetes cases. The incidence of HMA was 38% (53 patients) in the postprotocol group, compared with 43% (60 patients) in the preprotocol group, but this difference was not statistically significant (P = .365). Furthermore, the total chloride load per kg in the first 24 hours showed no statistical significance between the pre- and postgroups (mean 11 ± 5 and 11 ± 5, respectively; P = .665). Similarly, length of stay also showed no significant difference between the pre- and postprotocol groups (mean 3 ± 2 vs 4 ± 3, respectively; P = .102). This study examines the comparative effectiveness of 2 insulin concentrations in DKA treatment. Changing insulin concentrations did not influence the incidence of HMA.

The incidence of cerebral edema in pediatric patients with diabetic ketoacidosis: a retrospective study

OBJECTIVE

Cerebral edema is a severe and potentially fatal complication of diabetic ketoacidosis (DKA), particularly in pediatric patients. Despite its clinical significance, limited data exist on its incidence and associated risk factors in resource-limited settings. This study aimed to determine the incidence of cerebral edema in pediatric patients with DKA and investigate potential contributing factors. This retrospective study analyzed data from 270 pediatric DKA patients admitted to the Children's Medical Center Hospital, Tehran, between March 2018 and March 2020. Patients aged 1 day to 18 years were included based on standard DKA diagnostic criteria (blood glucose > 250 mg/dL, pH < 7.3, bicarbonate < 18 mEq/L, and ketonemia/ketonuria). Patients with incomplete records or pre-existing neurological conditions were excluded. The statistical analyses included independent t-tests and Fisher's exact tests.

RESULTS

The incidence of cerebral edema was 6.67%. Elevated blood glucose levels at admission were significantly associated with cerebral edema (P = 0.01), suggesting a potential role in its pathophysiology. Additionally, a strong correlation was observed between cerebral edema and ICU admission (P < 0.001), indicating a more severe disease course. The results suggest that early glucose control and neurological monitoring are critical for preventing adverse outcomes such as cerebral edema in pediatric DKA patients.

Diabetic Ketoacidosis in Pediatric Emergency Medicine: Risk Factors, Myths, and Evidence-Based Management of Complications

Purpose

Diabetic ketoacidosis (DKA) is a common condition among type 1 diabetics, commonly affecting those below the age of 20.

Methods

A comprehensive literature search was conducted in databases like PubMed to identify primary studies conducted in children with DKA. Finally, 79 studies were included for qualitative synthesis.

Results

The disease is characterized by acute-onset metabolic and pathological derangements, necessitating immediate intervention. With the rising incidence, concerns have been emerging regarding the disparities in the presentation and treatment of DKA among different countries with inequitable resources. Within its management lies the common misconceptions, both among patients and primary physicians, prohibiting an optimistic approach to the disease. Pediatric children in particular need specialized treatment and care during an episode of DKA due to its long-term cognitive and neurological sequelae. Hence, efforts have been undertaken to ensure minimization of neurological damage when treating DKA. While guidelines are in place for treatment of DKA, there are considerable differences in their protocols across different regions.

Conclusion

It is imperative to analyze recent evidence and continually update treatment guidelines for DKA. Additionally, maximal efforts need to be taken to bridge the gap between different nations, allowing accessibility to equitable resources to all.

Hyperchloremia and Prolonged Acidosis During Treatment for Pediatric Diabetic Ketoacidosis

OBJECTIVES

Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis with a high anion gap secondary to ketonemia. Intravenous hydration fluids used in treatment can cause chloride overload, leading to hyperchloremic metabolic acidosis (HMA). The development of HMA can lead to the persistence of acidosis despite the resolution of ketonemia.

METHODS

A total of 178 DKA episodes in 153 patients treated between January 2013 and October 2023 were included in the study. Creatine-based glomerular filtration rate and HbA1c value at admission and venous blood gas parameters (pH, actual bicarbonate, base deficit), anion gap, chloride-corrected bicarbonate, nonchloride base deficit, and sodium and chloride measured at 0, 2, 4, 6, 9, 12, 18 and 24 hours were evaluated.

RESULTS

Hyperchloremia was detected in 69.3% of participants and developed at a mean of 6.3 (±4.3) hours of treatment. The incidence of hyperchloremia increased with the duration of treatment; the rates were 8.4%, 51.3%, 65%, 76.2%, 75.5%, and 80% at 0, 6, 9, 12, 18, and 24 hours of treatment, respectively. The group with hyperchloremia had more severe acidosis, a higher HbA1c value, and a longer resolution time. At the 12th hour of treatment, acidosis continued based on pH and HCO 3 levels, whereas the hyperchloremia group exhibited a low anion gap (mean 12.8). At the 6th hour of treatment, the resolution rates were significantly lower in the hyperchloremia group based on the pH and HCO 3 levels but increased when assessed by chloride-corrected HCO 3 and anion gap.

CONCLUSIONS

During treatment of DKA, monitoring anion gap, blood ketones, and Cl - /Na + ratio or using regression equations in addition to routine acid-base parameters may help differentiate DKA from HMA and prevent prolonged intravenous treatment.

Mitochondrial proteins as therapeutic targets in diabetic ketoacidosis: evidence from Mendelian randomization analysis

Introduction

Diabetic ketoacidosis (DKA) is a severe and potentially fatal acute complication in diabetic patients, commonly occurring in type 1 diabetes (T1D) but also seen in type 2 diabetes (T2D). The pathogenesis of DKA involves complex physiological processes that are not fully understood, especially the role of mitochondria. Mitochondria, known as the powerhouse of cells, plays a crucial role in oxidative phosphorylation and ATP production, which is vital in various metabolic diseases, including diabetes. However, the exact causal relationship between mitochondrial dysfunction and DKA remains unclear.

Methods

This study employed Mendelian randomization (MR) analysis and protein-protein interaction (PPI) networks to systematically explore the causal relationships between mitochondrial DNA copy number (mtDNA-CN) and specific mitochondrial proteins with DKA. We used bidirectional MR analysis and genome-wide association study (GWAS) data from openGWAS database to investigate the causal effects of mtDNA-CN and 64 mitochondrial-related proteins on DKA and its subtypes (T1DKA, T2DKA, unspecified-DKA).

Results

The study revealed that increased mtDNA-CN significantly reduces the risk of DKA, whereas the effect of DKA on mtDNA-CN was not significant. Mitochondrial-related proteins such as MRPL32, MRPL33, COX5B, DNAJC19, and NDUFB8 showed a negative causal relationship with DKA, indicating their potential protective roles. Conversely, ATP5F1B and COX4I2 have a positive causal relationship with DKA, indicating that excessive ATP production in diabetic patients may be detrimental to health and increase the risk of severe complications such as DKA.

Discussion

The results emphasize the necessity of protecting mitochondrial function in order to reduce the risk of DKA. The study offers novel perspectives on the molecular pathways involved in DKA, emphasizing the critical functions of mt-DNA and distinct proteins. These evidences not only enhance our comprehension of the implications of mitochondrial dysfunction in diabetes-related complications but also identify potential therapeutic targets for individualized treatment approaches, thereby making a substantial contribution to clinical care and public health initiatives.

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

AIM

To determine the comparative effectiveness of fluid schemes for children with diabetic ketoacidosis (DKA).

METHODS

We conducted a systematic review with an attempt to conduct network meta-analysis (NMA). We searched MEDLINE, EMBASE, CENTRAL, Epistemonikos, Virtual Health Library, and gray literature from inception to July 31, 2022. We included randomized controlled trials (RCTs) in children with DKA evaluating any intravenous fluid schemes. We planned to conduct NMA to compare all fluid schemes if heterogeneity was deemed acceptable.

RESULTS

Twelve RCTs were included. Studies were heterogeneous in the population (patients and DKA episodes), interventions with different fluids (saline, Ringer's lactate (RL), and polyelectrolyte solution-PlasmaLyte®), tonicity, volume, and administration systems. We identified 47 outcomes that measured clinical manifestations and metabolic control, including single and composite outcomes and substantial heterogeneity preventing statistical combination. No evidence was found of differences in neurological deterioration (main outcome), but differences were found among interventions in some comparisons to normalize acid-base status (∼2 h less with low vs. high volume); time to receive subcutaneous insulin (∼1 h less with low vs. high fluid rate); length of stay (∼6 h less with RL vs. saline); and resolution of the DKA (∼3 h less with two-bag vs. one-bag scheme). However, available evidence is scarce and poor.

CONCLUSIONS

There is not enough evidence to determine the best fluid therapy in terms of fluid type, tonicity, volume, or administration time for DKA treatment. There is an urgent need for more RCTs, and the development of a core outcome set on DKA in children.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis

Introduction

Our aims were to determine whether anion gap normalization time (AGNT) correlates with risk factors related to the severity of diabetic ketoacidosis (DKA) in children, and to characterize AGNT as a criterion for DKA resolution in children admitted with moderate or severe disease.

Methods

A ten-year retrospective cohort study of children admitted to the intensive care unit with DKA. We used a survival analysis approach to determine changes in serum glucose, bicarbonate, pH, and anion gap following admission. Using multivariate analysis, we examined associations between patients' demographic and laboratory characteristics with delayed normalization of the anion gap.

Results

A total of 95 patients were analyzed. The median AGNT was 8 h. Delayed AGNT (>8 h) correlated with pH < 7.1 and serum glucose >500 mg/dL. In multivariate analysis, glucose >500 mg/dL was associated with an increased risk for delayed AGNT, by 3.41 fold. Each 25 mg/dL elevation in glucose was associated with a 10% increment in risk for delayed AGNT. Median AGNT preceded median PICU discharge by 15 h (8 vs. 23 h).

Discussion

AGNT represents a return to normal glucose-based physiology and an improvement in dehydration. The correlation observed between delayed AGNT and markers of DKA severity supports the usefulness of AGNT for assessing DKA recovery.

Case Report: Diabetic Ketoacidosis During Pregnancy Due to Insulin Omission

Diabetic ketoacidosis is an acute and severe complication commonly occurring in individuals with type-1 diabetes mellitus due to absolute insulin deficiency. A 28-year-old Black woman, gravida 2, para 2, secondary school teacher was admitted at 31 weeks of gestation to the obstetric ward on August 12/2022 with a two-day history of nausea and vomiting. She had a history of insulin-dependent diabetes mellitus four years earlier. She missed her insulin dose one day due to traveling to the village for greeting her family. She presented with a two-day history of nausea and vomiting, and a one-day history of shortness of breath, abdominal tenderness, hypotension, elevated heart rate, increased respiratory rate, frequent urination, and fatigue. Ketone testing done using her urine sample showed ketonuria of 3+. Her chest X-ray revealed coarse crackles on auscultation. Her breath odor revealed acetone-smelling breathing. Upon admission, she was treated with insulin infusion for 24 hours and 60 milliequivalents per liter of potassium chloride intravenously was also initiated. On the same day, 0.9% of normal saline 500 mL was initiated intravenously stat and repeats until systolic blood pressure was greater than 90 mmHg. The main objectives of diabetic ketoacidosis management are to restore volume status, normalize hyperglycemia, replace electrolytes lost, and lower ketoacidosis.

Adherence to the 2015 and 2020 British Society of Paediatric Endocrinology and Diabetes guidelines and outcomes in critically ill children with diabetic ketoacidosis: a retrospective cohort study

OBJECTIVES

To compare clinical management and key outcomes of critically ill children with diabetic ketoacidosis (DKA) in two cohorts (2015 cohort: managed according to the 2015 British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines; 2020 cohort: managed according to the 2020 BSPED guidelines).

DESIGN

Retrospective cohort study using prospectively collected data.

SETTING

A critical care advice and transport service based in London, and referring hospitals within the critical care network.

PATIENTS

All children 0-17 years referred for advice and/or critical care transport with a clinical diagnosis of DKA over a 30-month period (from September 2018 to March 2021).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Admission to intensive care unit (ICU), clinically diagnosed cerebral oedema and death.

RESULTS

There were significant differences in fluid and insulin administration practices between the 2015 and 2020 cohorts (fluid bolus >20 mL/kg: 3% vs 30%, p<0.001; median total fluid given in the first 24 hours: 84 mL/kg vs 117 mL/kg, p<0.01; starting insulin infusion rate 0.1 U/kg/hour: 54% vs 31%, p<0.01). However, these differences were consistent with guideline recommendations (initial fluid infusion rate within 5% of guideline-recommended rate: 80% in the 2015 group vs 84% in the 2020 group). There were no significant differences in outcomes (ICU admission: 26% vs 35%, p=0.2; cerebral oedema: 21% vs 23%, p=0.8).

CONCLUSIONS

Our study findings indicate that changes to fluid and insulin administration occurred after the 2020 BSPED guideline publication, with strong adherence to the guideline, but these changes were not associated with changes in key outcomes.