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Patino-Galarza D, Duque-Lopez A, Cabra-Bautista G, Calvache JA, Florez ID. Fluids in the treatment of diabetic ketoacidosis in children: A systematic review. J Evid Based Med 2024. [PMID: 38572835 DOI: 10.1111/jebm.12603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 03/20/2024] [Indexed: 04/05/2024]
Abstract
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.
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Affiliation(s)
| | | | - Ginna Cabra-Bautista
- Department of Pediatrics, Universidad del Cauca, Popayán, Colombia
- Pediatric Emergency Room, Susana López de Valencia Hospital, Popayán, Colombia
| | - Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands
| | - Ivan D Florez
- Department of Pediatrics, Universidad de Antioquia, Medellín, Colombia
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
- Pediatric Intensive Care Unit, Clínica Las Américas-AUNA, Medellín, Colombia
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Doğan D, Gökalp HDC, Eren E, Sağlam H, Tarım Ö. Revised one-bag IV fluid protocol for pediatric DKA: a feasible approach and retrospective comparative study. J Trop Pediatr 2024; 70:fmae003. [PMID: 38339873 PMCID: PMC10858344 DOI: 10.1093/tropej/fmae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
- Durmuş Doğan
- Department of Pediatric Endocrinology, School of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Türkiye
| | - Hatice D C Gökalp
- Department of Pediatric Medicine, Pediatric Endocrinology, Bursa City Hospital, Bursa, Türkiye
| | - Erdal Eren
- Department of Pediatric Endocrinology, School of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Halil Sağlam
- Department of Pediatric Endocrinology, School of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Ömer Tarım
- Department of Pediatric Endocrinology, School of Medicine, Bursa Uludag University, Bursa, Türkiye
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Lazar I, Wizeman-Orlov D, Hazan G, Orbach A, Haim A, Cavari Y, Feinstein Y, Neeman E, Hershkovitz E, Faingelernt Y. The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis. Front Pediatr 2023; 11:1198581. [PMID: 37334219 PMCID: PMC10275565 DOI: 10.3389/fped.2023.1198581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023] Open
Abstract
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.
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Affiliation(s)
- Isaac Lazar
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Dorit Wizeman-Orlov
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Guy Hazan
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Asaf Orbach
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Alon Haim
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Pediatric Endocrinology Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Yuval Cavari
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eitan Neeman
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eli Hershkovitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Pediatric Endocrinology Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Yaniv Faingelernt
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
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Bereda G. Case Report: Diabetic Ketoacidosis During Pregnancy Due to Insulin Omission. OAEM 2022. [DOI: https://doi.org/10.2147/oaem.s388941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Bereda G. Case Report: Diabetic Ketoacidosis During Pregnancy Due to Insulin Omission. OAEM 2022; 14:615-618. [PMID: 36411797 DOI: 10.2147/oaem.s388941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gudisa Bereda
- Department of Pharmacy, Negelle Health Science College, Negelle, Oromia Regional State, 1000, Ethiopia
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Edwards VM, Procter C, Jones AJ, Randle E, Ramnarayan P. 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. Arch Dis Child 2022; 107:archdischild-2021-323641. [PMID: 35710720 DOI: 10.1136/archdischild-2021-323641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/26/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Victoria Mary Edwards
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Claire Procter
- Department of Paediatrics, Red Cross Children's Hospital, Cape Town, South Africa
| | - Andrew J Jones
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Elise Randle
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery, Imperial College London Faculty of Medicine, London, UK
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Affiliation(s)
- Scott L. Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fran Balamuth
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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