Diabetic Ketoacidosis in Infants, Children, and Adolescents

Wolfsdorf, Joseph I.; Glaser, Nicole; Sperling, Mark A.

doi:10.2337/dc06-9909

Cited by 345 publications

(214 citation statements)

References 117 publications

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“…16 We have provided a formula to calculate vpH from HCO3, which suggests HCO3 values of 15, 9, and 5 correspond to vpH levels of 7.3, 7.2, and 7.1, respectively (Table 3). Although these are consistent with pediatric guideline cutoffs 3,17 of 15 and 5 mmol/L to diagnose DKA and severe DKA, respectively, these cutoffs had lower sensitivity (82.1% and 52.4%) compared with higher cutoffs, whereas specificity was only slightly higher (Table 4) Although minor differences exist for the criteria to diagnose DKA, 3,8,[17][18][19] the most commonly used definition in pediatrics is a combination of pH ,7.3, HCO3 ,15-18 mmol/L, ketonuria or ketonemia, and hyperglycemia. Some definitions add the anion gap 18 as a measure of metabolic acidosis.…”

Section: Discussionsupporting

confidence: 75%

“…Venous pH ,7.1 or serum HCO3 ,5 mmol/L has been used to define severe DKA. 3,8 These definitions are incorporated into hospital practice guidelines, and emergency department physicians and pediatricians often base management decisions, for example, admission to hospital and use of intravenous versus subcutaneous insulin therapy, on the vpH value. However, in remote or limited resource settings, VBG is not readily available.…”

Section: Methodsmentioning

confidence: 99%

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Use of Serum Bicarbonate to Substitute for Venous pH in New-Onset Diabetes

Oettingen¹,

Wolfsdorf

Feldman

et al. 2015

Pediatrics

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OBJECTIVE: To investigate whether serum bicarbonate (HCO3) levels can be used to accurately diagnose diabetic ketoacidosis (DKA) and classify its severity in children with new-onset diabetes mellitus (NODM). METHODS:Retrospective study of all patients with NODM presenting to Boston Children's Hospital from October 1, 2007, to July 1, 2013. DKA was defined as blood glucose $200 mg/dL, venous pH (vpH) ,7.3, and urine ketones $2+, and severe DKA as vpH ,7.1. Linear regression was used to assess serum HCO3 as a predictor of vpH, and logistic regression to evaluate serum HCO3 as a predictor of DKA and severe DKA.RESULTS: Of 690 study cohort subjects (47% girls, age 10.8 6 4.3 years, 76.7% white), 19.4% presented with DKA. The relationship between serum HCO3 and vpH was log-linear (r = 0.87, 95% CI 0.85-0.89, P , .001). HCO3 predicted vpH (R 2 0.75, P , .001) using the formula Diabetes mellitus in youth is common, with an estimated worldwide annual incidence of 80 000 children younger than 15 years 1 and the incidence is rising. 2 Diabetic ketoacidosis (DKA) at presentation of new-onset diabetes mellitus (NODM) occurs in approximately 15% to 70% of patients in Europe and North America. 3 The incidence of DKA at presentation is higher in younger children, ethnic minorities, families of lower socioeconomic status, and regions with a lower prevalence of diabetes, 3-7 which includes many resource-limited countries.In many pediatric academic medical centers in the United States, the standard initial diagnostic evaluation for children with NODM and especially those suspected to have DKA includes a panel of laboratory tests to measure venous blood gas (VBG) and the concentrations of plasma glucose, serum electrolytes, serum bicarbonate (HCO3), serum urea nitrogen (SUN), creatinine, hemoglobin A1c (HbA1c), and serum or urinary ketones. Acidemia is defined as arterial pH ,7.35 or venous pH (vpH) ,7.3, and traditionally, a vpH ,7.3 or a serum HCO3 ,15 mmol/L is used to confirm the diagnosis of DKA, with lower values of both indicating greater severity of the condition. Venous pH ,7.1 or serum HCO3 ,5 mmol/L has been used to define severe DKA. 3,8 These definitions are incorporated into hospital practice guidelines, and emergency department physicians and pediatricians often base management decisions, for example, admission to hospital and use of intravenous versus subcutaneous insulin therapy, on the vpH value. However, in remote or limited resource settings, VBG is not readily available.A recent study of pediatric patients seen in an emergency department suggested that the venous HCO3 concentration accurately predicts abnormal vpH in children with DKA. 9 Similarly, in adults, venous HCO3 concentrations predicted arterial pH with a high degree of sensitivity and specificity. 10 The objective of our study was to evaluate the ability of serum HCO3, measured at presentation, as part of a routine basic metabolic panel, to accurately predict DKA and classify its severity in a large population of youth with NODM. METHODS Stu...

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Section: Discussionsupporting

confidence: 75%

Section: Methodsmentioning

confidence: 99%

Use of Serum Bicarbonate to Substitute for Venous pH in New-Onset Diabetes

Oettingen¹,

Wolfsdorf

Feldman

et al. 2015

Pediatrics

Self Cite

View full text Add to dashboard Cite

show abstract

“…With the administration of insulin, the blood glucose levels will slowly decrease and the signs and symptoms of hyperglycemia causing metabolic acidosis will subside. 8 In case study 2, PN was losing bicarbonate in the stool as a result of gastroenteritis and was hypovolemic, both leading to metabolic acidosis. The underlying cause of the acidosis was loss of bicarbonate; therefore, the metabolic acidosis would resolve once the gastroenteritis was resolved and bicarbonate was not lost in the stool.…”

Section: Treatmentmentioning

confidence: 97%

“…Lipolysis that occurs as a result of insulin deficiency leads to oxidation of free fatty acids by the liver and subsequent production of ketoacids. 8 Calculating the anion gap helps clinicians decipher the cause of the acidosis. In this case, the accumulation of ketoacids in the bloodstream created an elevated anion gap metabolic acidosis.…”

Section: Case Studymentioning

confidence: 99%