Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital

Ronsley, Rebecca; Islam, Nazrul; Ronsley, Claire; Metzger, Daniel L.; Panagiotopoulos, Constadina

doi:10.1111/pedi.12556

Cited by 10 publications

(6 citation statements)

References 16 publications

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“…The management of DKA in any setting, both for patients with newly or previously diagnosed T1DM, can be divided into four physiologic principles which are restoration of fluid volume, inhibition of lipolysis, correction of electrolyte abnormalities and correction of acidosis. Delayed, insufficient or inappropriate treatment is a potential risk for developing complications of DKA (22). The timing of fluid therapy as an initial treatment has a considerable effect on the outcome of DKA and it is recommended that it should be given within the first hour (23).…”

Section: Discussionmentioning

confidence: 99%

The Effects of Prehospital Care on Outcome in Pediatric Diabetic Ketoacidosis

Turan

Yurtseven

Basa

et al. 2020

Jcrpe

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Despite the guidelines, significant variations can be encountered in initial therapy for pediatric diabetic ketoacidosis (DKA) in the prehospital setting. These variations occur mostly in fluid administration, insulin dosing, route of administration, and other aspects of the initial resuscitation and stabilization. The aim was to identify the effect of transport care on outcomes in children with DKA admitted to the emergency department (ED). Methods: Patients admitted to a tertiary-care pediatric ED between 2015-2019 with a diagnosis of DKA were retrospectively identified. Details of pre-pediatric ED care, including transport modality, patient demographics, clinical features, laboratory evaluation, fluid therapy, insulin dosing, and short-term outcome were recorded. Results: The study cohort included 147 episodes of DKA in 136 patients aged 9 months-21 years. Emergency Medical Service (EMS) transported only 37.4% of cases. EMS utilization rate was significantly higher (p=0.003) in severe cases, most of whom were >10 years (p=0.04). During transport 85% received intravenous fluid bolus. Use of fluids other than normal saline was significantly higher when transport time was >30 minutes (p=0.001). Acute kidney injury and cerebral edema developed in 21.7% and 7.4% of episodes, respectively. These complications were more common in the EMS transport group. Pediatric intensive care admission rate was also higher in the EMS compared to the non-EMS group (p=0.01) Conclusion: Parents did not call the ambulance for most cases although a higher complication rate occurred in EMS patients. EMS providers and referral facilities should improve their knowledge of pediatric DKA.

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Section: Discussionmentioning

confidence: 99%

The Effects of Prehospital Care on Outcome in Pediatric Diabetic Ketoacidosis

Turan

Yurtseven

Basa

et al. 2020

Jcrpe

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“…Even with local protocols in place, studies have shown that interpretation of such protocols may vary, and adherence is still imperfect. 1,15,16 Using the TEM, we were able to identify factors that may contribute to nonadherence. In terms of threats, cases where it was a first-time presentation of T1DM or where the initial assessment was done by a learner (either medical student or resident), were less likely to have the order set filled out from the beginning.…”

Section: Discussionmentioning

confidence: 99%

“…Our finding is in agreement with previous studies that have highlighted the differences in acute DKA management both between different hospitals and among physicians within a given center. Even with local protocols in place, studies have shown that interpretation of such protocols may vary, and adherence is still imperfect 1,15,16 …”

Section: Discussionmentioning

confidence: 99%

Safety Audits in the Emergency Department

et al. 2020

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Objectives: This study aims to better understand factors that impact management of patients with diabetic ketoacidosis (DKA) in the pediatric emergency department (ED) by novel application of the threat-and-error model, commonly used in the aviation industry.Methods: This study was a retrospective chart review of all patients diagnosed with DKA and managed in our pediatric ED during a 1-year period. A "flight plan" was created for each patient's ED visit, from triage to final disposition. Each flight was analyzed with the goal of identifying threats and errors that may impact patients' clinical status or management. Particular focus was placed on physicians' adherence to hospital and provincial DKA protocols. Unintended patient states or outcomes were also noted.Results: A total of 46 patient flights were outlined and analyzed. A total of 146 threats were identified, affecting 43 (93%) patient flights. No flight was error-free. Errors in communication and lack of adherence to protocol were the most common types of errors. Unintended patient states occurred in 30 cases (65%), some of which were preceded by at least 1 error. There were no cases of cerebral edema or death. Conclusions:It is important to identify and appropriately mitigate threats and errors that commonly occur during initial management of DKA in the ED to prevent unintended states and patient morbidity. This study demonstrates the threat-and-error model as a potentially useful tool for focusing quality improvement initiatives in the pediatric ED setting.

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“…Several RCTs have been conducted in children with DKA. As a result, the most effective and safest fluid and infusion scheme to manage DKA in children remains unknown 12–14 . Therefore, through a systematic review and network meta‐analysis (NMA), this work sought to determine the comparative effectiveness—in terms of neurological deterioration and metabolic control—of the fluid schemes used to rehydrate children with DKA.…”

Section: Introductionmentioning

confidence: 99%

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

Patino‐Galarza,

Duque‐Lopez,

Cabra‐Bautista

et al. 2024

J Evidence Based Medicine

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AimTo determine the comparative effectiveness of fluid schemes for children with diabetic ketoacidosis (DKA).MethodsWe 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.ResultsTwelve 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.ConclusionsThere 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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Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital

Cited by 10 publications

References 16 publications

The Effects of Prehospital Care on Outcome in Pediatric Diabetic Ketoacidosis

The Effects of Prehospital Care on Outcome in Pediatric Diabetic Ketoacidosis

Safety Audits in the Emergency Department

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

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