Low Morbidity and Mortality in Children with Diabetic Ketoacidosis Treated with Isotonic Fluids

White, Perrin C.; Dickson, Bryan A.

doi:10.1016/j.jpeds.2013.02.005

Cited by 34 publications

(44 citation statements)

References 26 publications

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“…Hence, we decided to add insulin infusion to better define the population with a true DKA diagnosis. Other studies 17,19,20 have used only the 250.1 ICD-9 code that likely included patients who were not undergoing DKA, which might explain the relatively large "DKA" patient populations and conclusions confounded by selection bias due to poor case ascertainment, a common pitfall with electronic medicine data collection. Similarly, our cerebral edema case ascertainment is based on both ICD-9 code as well as having received mannitol or hypertonic saline as therapy to avoid such pitfalls.…”

Section: Discussionmentioning

confidence: 99%

Improving Care for Pediatric Diabetic Ketoacidosis

Koves

Leu²,

Spencer³

et al. 2014

Pediatrics

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OBJECTIVE: We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures.METHODS: Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS:Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations. CONCLUSIONS:Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities. Pediatrics 2014;134:e848-e856 Dr Koves drafted, wrote, and submitted the manuscript; developed the design for manuscript and metrics data definitions; interpreted the data; formatted the manuscript; facilitated contributions; developed the figures, tables, references, and reference formatting; and facilitated publication of the final version; she provided oversight for all aspects of the development of the diabetic ketoacidosis (DKA) clinical standard work package; Dr Leu made substantial contributions to the conception and revision of clinical guidelines, architected and updated clinical decision supports used to support the project, reviewed analysis of data, composed a portion of the original manuscript, and edited all of the final manuscript; Ms Spencer performed data analysis and statistical significance testing and contributed writing to the methods of evaluation, results, and analysis sections; Ms Popalisky contributed writing to the methods and discussion sections and assisted with review and revising drafts of the manuscript; Ms Drummond contributed to writing the methods and discussion sections...

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Section: Discussionmentioning

confidence: 99%

Improving Care for Pediatric Diabetic Ketoacidosis

Koves

Leu²,

Spencer³

et al. 2014

Pediatrics

View full text Add to dashboard Cite

show abstract

“…Subsequent fluid management (deficit replacement) can be accomplished with 0.45% to 0.9% saline or a balanced salt solution (Ringer's lactate, Hartmann's solution or Plasmalyte) Fluid therapy should begin with deficit replacement plus maintenance fluid requirements. All children will experience a decrease in vascular volume when plasma glucose concentrations fall during treatment; therefore, it is essential to ensure that they receive sufficient fluid and salt to maintain adequate tissue perfusion. Deficit replacement should be with a solution that has a tonicity in the range 0.45% to 0.9% saline, with added potassium chloride, potassium phosphate or potassium acetate (see below under potassium replacement) . Decisions regarding use of isotonic vs hypotonic solution for deficit replacement should depend on clinician judgment based on the patient's hydration status, serum sodium concentration and osmolality. In addition to providing the usual daily maintenance fluid requirement, replace the estimated fluid deficit at an even rate over 24 to 48 hours .…”

Section: Clinical and Biochemical Monitoringmentioning

confidence: 99%

“…At this point, any remaining deficits were replenished by oral intake once DKA had resolved and patients were transitioned to subcutaneous insulin Satisfactory outcomes have also been reported using an alternative simplified method: After the initial fluid administration of 20 mL/kg of normal saline, 0.675% saline (3/4 normal saline, 115.5 mmol sodium) is infused at 2 to 2.5 times the usual maintenance rate of fluid administration regardless of the degree of dehydration, and decreased to 1 to 1.5 times the maintenance rate after 24 hours, or earlier if acidosis resolved Clinical assessment of hydration status and calculated effective osmolality are valuable guides to fluid and electrolyte therapy.…”

Section: Clinical and Biochemical Monitoringmentioning

confidence: 99%

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state

et al. 2018

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“…It is readily complicated by cerebral edema, hypoglycemia and stroke and pneumomediastinum amongst other complications. The frequency of cerebral edema in ketoacidosis ranges from 0.39 to 0.5% with variable mortality and morbidity [2,3]. The early signs of cerebral edema are headache, deterioration in consciousness, confusion and unexplained changes in heart rate, respiratory rate and blood pressure.…”

Section: Introductionmentioning

confidence: 99%

Cerebrovascular Disease in a Newly Diagnosed Diabetic Adolescent: Case Report

Oludare¹

2017

EMIJ

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DiscussionDeath due to thrombosis occurs in 80% of diabetic patients and 75% of these deaths is attributed to cardiovascular complications AbstractPaediatric stroke is a rare occurrence with an incidence ranging from 1.3-13/ 100,000 of children. Little is known about the association of diabetic ketoacidosis and stroke. Also, the frequency of stroke in diabetic ketoacidosis is not defined as there are no reported cases. We report a case of a right-handed 14 year-old male adolescent referred to Ekiti State University Teaching Hospital (EKSUTH) from a peripheral hospital where he was managed for typhoid sepsis, however at presentation he had clinical and laboratory features of diabetic ketoacidosis. Diabetic ketoacidosis was managed with insulin infusion and recommended intravenous fluids. When the patient became euglycaemic and regained consciousness, he was noticed to have developed features of left hemispheric cerebrovascular disease which was confirmed with cranial CT and patient was managed as such till discharge from the hospital.

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Low Morbidity and Mortality in Children with Diabetic Ketoacidosis Treated with Isotonic Fluids

Cited by 34 publications

References 26 publications

Improving Care for Pediatric Diabetic Ketoacidosis

Improving Care for Pediatric Diabetic Ketoacidosis

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state

Cerebrovascular Disease in a Newly Diagnosed Diabetic Adolescent: Case Report

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