Presenting predictors and temporal trends of treatment-related outcomes in diabetic ketoacidosis

Horvat, Christopher M.; Ismail, Heba M.; Au, Alicia K.; Garibaldi, Luigi; Siripong, Nalyn; Kantawala, Sajel; Aneja, Rajesh K.; Hupp, Diane; Kochanek, Patrick M.; Clark, Robert S. B.

doi:10.1111/pedi.12663

Cited by 5 publications

(6 citation statements)

References 31 publications

(32 reference statements)

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“…Only 68% of centres reported adoption of the ISPAD guidelines to manage DKA, and there was great variation in the approach to management 1. These data were consistent with a comprehensive study of DKA incidence during a 10-year follow-up in Italy by Cherubini et al ,2 and with studies published in the same period in other European3–5 and Extra European countries 6 7…”

Section: Introductionsupporting

confidence: 71%

Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0–18 years

et al. 2019

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ObjectiveAfter a previous survey on the incidence of diabetic ketoacidosis (DKA) at onset of type 1 diabetes in children in 2013–2014 in Italy, we aimed to verify a possible decline in the incidence of DKA at onset during a national prevention campaign.DesignProspective observational study.SettingMulticentre study throughout Italy.InterventionNational awareness campaign started in November 2015 and held until December 2017.PatientsDuring 2016 and 2017 we collected data on all patients aged 0–18 years with new-onset diabetes.Main outcome measuresDKA (pH <7.30), severe DKA (pH <7.1), DKA in children below 6 years and DKA treatment according to the Italian Society for Pediatric Endocrinology and Diabetology (ISPED) protocol were evaluated.ResultsRecords (n=2361) of children with newly diagnosed type 1 diabetes were collected from 58 out of 68 (85.3%) centres of the original survey participants and 100% of the previously surveyed tertiary centres. Overall, DKA was observed in 1124 patients, with an increased rate when compared with the previous survey (47.6% vs 38.5%, p=0.002), and severe DKA in 15.3%. In children below 6 years, DKA was observed in 323 out of 617 (52.5%) and severe DKA in 16.7%; in this age group, occurrence of DKA reduced by 21.3% (p=0.009). DKA treatment according to the ISPED guidelines was adopted in 95% of the centres, with a 27% improvement (p=0.025).ConclusionsDuring a 2-year awareness campaign, DKA at onset of diabetes in children and adolescents 0–18 years is still common and increased when compared with the 2013–2014 survey.

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Section: Introductionsupporting

confidence: 71%

Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0–18 years

et al. 2019

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“…Among the 6 studies identified which addressed our primary objective, 5 studies found no significant association between younger age and higher risk of CE (5e7, 18,19). In contrast, a large case series of fair quality, which included both cases from the literature and cases followed by the author, found that age <5 years was associated with higher risk of CE (17).…”

Section: Discussionmentioning

confidence: 94%

“…They did find a significant association between a new diagnosis of diabetes and CE. Horvat et al (18) published a retrospective single-centre study from the United States using electronic health records to determine the effect of 2 systematic changes in hospital management of DKA, which included mandatory admission to the pediatric intensive care unit and implementation of a standardized management pathway for DKA. They used stepwise logistic regression analysis to determine the factors associated with each DKA outcome, including CE.…”

Section: Discussionmentioning

confidence: 99%

“…No statistically significant difference in age between CE cases and matched control subjects with DKA was found (7). Two recent retrospective studies in the United States (18) and India (19) found no statistically significant difference in age between children with and without CE. DKA Table 2 (20e46) describes the findings of the 27 studies published over the last 30 years which reported the incidence of DKA or severe DKA based on age categories.…”

Section: Methodsmentioning

confidence: 95%

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Is Age a Risk Factor for Cerebral Edema in Children With Diabetic Ketoacidosis? A Literature Review

Glackin

Metzger

Hanås

et al. 2020

Canadian Journal of Diabetes

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Key MessagesPublished data do not support the view that young age is a risk factor for cerebral edema development in children with diabetic ketoacidosis at the time of diagnosis. Younger children are at a higher risk for the development of diabetic ketoacidosis, in particular during the first 2 to 3 years of life. Whether diabetic ketoacidosis is more severe in younger children remains unclear. Keywords:cerebral edema children diabetic ketoacidosis review type 1 diabetes younger age a b s t r a c t 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.Ó 2019 Canadian Diabetes Association.Mots clés: oedème cérébral enfants acidocétose diabétique revue diabète de type 1 de plus bas âge r é s u m é L'oedème cérébral (OC) est une complication rare, mais potentiellement fatale de l'acidocétose diabétique (ACD) chez les enfants atteints du diabète de type 1. On mentionne souvent que l'OC est plus fréquent chez les jeunes enfants. L'objectif principal de la présente étude était d'examiner les données probantes qui montrent que les enfants de plus bas âge qui sont atteints d'ACD sont exposés au risque de développer un OC. L'objectif secondaire était d'évaluer si les enfants de plus bas âge sont exposés à un risque plus élevé d'ACD et d'ACD grave. Dans la revue de littérature réalisée, nous avons sélectionné les études qui rapportaient la fréquence de l'OC, l'ACD et l'ACD grave chez les enfants âgés de < 3 ans et de 3

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“…Harmonizing these often-opposing visions necessitates a strategy that guides clinicians to available resources and the present standard of care while allowing sufficient leeway for individualizing regimens when necessary. Our first foray into our institution's electronic data examined the impact of our guidelines for the management of diabetic ketoacidosis (DKA) [4]. Access to the guideline was made available on the institution's intranet and a corresponding EHR PowerPlan (orderset) was implemented to facilitate clinician adherence and optimize the efficiency of the guidelines.…”

Section: Standardizing Without Protocolizing: Developing Institutionamentioning

confidence: 99%

The STELAR ICU: Leveraging Electronic Health Record Data to Foster Research and Optimize Patient Care

2018

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Electronic health records (EHR) combined with robust data collection systems can be used to simultaneously drive research and performance improvement initiatives. Our Smart, Transformative, EHR-based Approaches to Revolutionizing the Intensive Care Unit (STELAR ICU) consists of a framework of five best practices that make optimal use of objective data to guide clinicians caring for the sickest patients in our quaternary center. Our strategy has relied on an accessible data infrastructure, standardizing without protocolizing care, using technology to increase patient contact and time spent at the bedside, continuously re-evaluating performance in real-time, and acknowledging uncertainty by using electronic data to provide probabilistic weight to clinical decision-making. These strategies blur the lines between research and quality improvement, with the aim of achieving truly stellar patient outcomes.

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Presenting predictors and temporal trends of treatment-related outcomes in diabetic ketoacidosis

Abstract: Treatment-related outcomes improved over the entire study period and following a performance improvement intervention. The association of SBP with cerebral edema warrants further study.

Cited by 5 publications

References 31 publications

Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0–18 years

Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0–18 years

Is Age a Risk Factor for Cerebral Edema in Children With Diabetic Ketoacidosis? A Literature Review

The STELAR ICU: Leveraging Electronic Health Record Data to Foster Research and Optimize Patient Care

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