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

Abstract

ObjectivesTo 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).DesignRetrospective cohort study using prospectively collected data.SettingA critical care advice and transport service based in London, and referring hospitals within the critical care network.PatientsAll 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).InterventionsNone.Main outcome measuresAdmission to intensive care unit (ICU), clinically diagnosed cerebral oedema and death.ResultsThere 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).ConclusionsOur 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.

Fluid therapy in diabetic ketoacidosis

“…In children with DKA, current recommendations are to (i) assume a 10% fluid deficit, (ii) administer 10–20 ml/kg of saline over 30 min (rising to upto 40 ml/kg in hypotensive or shocked children), (iii) administer weight-based saline (6.5 ml/kg/h for 5–9.9 kg child; 6 ml/kg/h for 10–19.9 kg child; 5 ml/kg/h for 20–39.9 kg child and 4 ml/kg/h for ≥40 kg child) for 36 h, (iv) introduce dextrose containing solution (5% or 10% dextrose) once blood glucose level < 17mmol/l, and (v) introduce oral fluids once tolerated [7]. Evidence from the United Kingdom suggests that fluid resuscitation for children with DKA is largely consistent with the guideline recommendations and changed rapidly when the 2015 guidelines were updated in 2020 [8].…”