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Initial fluid management of diabetic ketoacidosis in children
1Department of Pediatrics, University of Alberta, Edmonton, Canada.
Insights
Pediatric fluid therapy for diabetic ketoacidosis (DKA) in emergency departments often exceeds recommended guidelines. This excessive fluid administration in children with DKA requires physician education to mitigate risks.
Area of Science:
- Pediatric Emergency Medicine
- Endocrinology
- Critical Care
Background:
- Diabetic ketoacidosis (DKA) is a serious complication of diabetes in children.
- Current recommendations for fluid therapy in pediatric DKA aim to restore hydration while avoiding fluid overload.
- Variations in DKA management protocols across different hospital levels may impact patient outcomes.
Purpose of the Study:
- To evaluate the adherence to current fluid therapy guidelines in the emergency department management of pediatric DKA.
- To compare fluid therapy practices for DKA between primary, secondary, and tertiary care settings.
- To identify potential areas for improvement in DKA management protocols for children.
Main Methods:
- A 5-year retrospective chart review of pediatric patients admitted with DKA at the University of Alberta Hospital.
- Analysis of presenting clinical and laboratory data, initial fluid therapy, and insulin dosage.
- Comparison of DKA management strategies based on the initial site of patient presentation.
Main Results:
- No significant clinical or biochemical differences were observed in DKA patients across primary, secondary, or tertiary hospitals.
- 84% of DKA cases received an initial saline bolus, with a mean fluid volume of 18.3 mL/kg within the first hour.
- A majority of patients (82% in primary/secondary, 67% in tertiary) received >10 mL/kg of fluid in the first hour, indicating excessive fluid administration.
Conclusions:
- Fluid management in pediatric DKA cases frequently exceeds recommended volumes.
- Current fluid therapy practices for DKA in children are not aligned with established guidelines.
- Enhanced education for emergency physicians is crucial to optimize fluid therapy and reduce the risk of neurological complications in pediatric DKA.
Abstract:
The purpose of this study was to review the emergency department management of children presenting in diabetic ketoacidosis (DKA) to determine if current recommendations for fluid therapy are practiced. A 5-year retrospective chart review was conducted of all pediatric patients admitted with DKA to the University of Alberta Hospital. Presenting clinical and laboratory data, the initial fluid therapy, and insulin dose were analyzed. The therapy was also compared between sites of initial presentation (primary, secondary, or tertiary hospital). A total of 49 cases of DKA in 37 patients were reviewed. There were no significant clinical or biochemical differences between patients presenting at the three levels of hospital. Forty-one cases (84%) were given a saline bolus and the mean fluid volume given by 1 hour was 18.3 mL/kg. In the first hour 82% of patients presenting at a primary or secondary centre and 67% of those at the tertiary centre received more than 10 mL/kg. This excessive fluid therapy was also evident after 4 hours. Fluid management of children in DKA is excessive and not in keeping with current recommendations. Education of emergency physicians is needed to reduce fluid therapy and the risk of neurologic complications.