A Multicenter Retrospective Survey regarding Diabetic Ketoacidosis Management in Italian Children with Type 1 Diabetes

Abstract

We conducted a retrospective survey in pediatric centers belonging to the Italian Society for Pediatric Diabetology and Endocrinology. The following data were collected for all new-onset diabetes patients aged 0–18 years: DKA (pH < 7.30), severe DKA (pH < 7.1), DKA in preschool children, DKA treatment according to ISPAD protocol, type of rehydrating solution used, bicarbonates use, and amount of insulin infused. Records (n = 2453) of children with newly diagnosed diabetes were collected from 68/77 centers (87%), 39 of which are tertiary referral centers, the majority of whom (n = 1536, 89.4%) were diagnosed in the tertiary referral centers. DKA was observed in 38.5% and severe DKA in 10.3%. Considering preschool children, DKA was observed in 72%, and severe DKA in 16.7%. Cerebral edema following DKA treatment was observed in 5 (0.5%). DKA treatment according to ISPAD guidelines was adopted in 68% of the centers. In the first 2 hours, rehydration was started with normal saline in all centers, but with different amount. Bicarbonate was quite never been used. Insulin was infused starting from third hour at the rate of 0.05–0.1 U/kg/h in 72% of centers. Despite prevention campaign, DKA is still observed in Italian children at onset, with significant variability in DKA treatment, underlying the need to share guidelines among centers.

High frequency of diabetic ketoacidosis at diagnosis of type 1 diabetes in Italian children: a nationwide longitudinal study, 2004–2013

“…In mainland Italy, DKA frequency at time of diabetes diagnosis (41.9%) was consistent with recent reports from other countries, such as France (43.9%)14 and Brazil (42.3%)15, and with a recent Italian study based on two years of observation (38.5%)7. The DKA frequency in Italian children at diagnosis of type 1 diabetes was somewhat higher than that reported in Austria (34.0%)5, Germany (21.1%)3, New Zealand (25.0%)16 and the U.S. (31.1%)17 and, disappointingly, close to twice that reported in Finland (22.4%)18 and Denmark (17.9%)19 and in Canada (18.6%)20.…”

“…Although the frequency of DKA varies widely between countries, levels of DKA at diagnosis of type 1 diabetes seem to be constant in Germany3, Great Britain4, Austria5 and the Unites States6. A recent Italian study on DKA incidence at diagnosis in Italy during the calendar years 2012–2013 showed a higher frequency of DKA in subjects under 18 years of age than that observed in Northern European countries7. The Parma campaign demonstrated the effectiveness of a public education programme in reducing the frequency of DKA at diabetes diagnosis in a restricted area.…”

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

“…There is wide geographic variation in the frequency of DKA at onset of diabetes; rates inversely correlate with the regional incidence of type 1 diabetes. Frequencies range from approximately 15% to 70% in Europe and North America . DKA at diagnosis is more common in younger children (especially <2 years of age), including infants with both transient and permanent neonatal diabetes (overall frequency 66%), often the consequence of diagnostic error or delayed treatment .…”

Interprofessional, multiple step simulation course improves pediatric resident and nursing staff management of pediatric patients with diabetic ketoacidosis

“…Skitch and Valani[23] looked at the protocols of thirteen pediatric tertiary centers in Canada and reported many differences in the management of DKA. In comparison, a survey in pediatric centers in the Italian Society for Pediatric Diabetology and Endocrinology recognized significant differences in DKA management among their centers as well[24]. Both articles reference the need for evidence-based guidelines to be utilized across the board for best practice[23,24].…”

“…In comparison, a survey in pediatric centers in the Italian Society for Pediatric Diabetology and Endocrinology recognized significant differences in DKA management among their centers as well[24]. Both articles reference the need for evidence-based guidelines to be utilized across the board for best practice[23,24]. Although, DKA is managed through different methods, preventative care for these patients is of utmost importance.…”