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Implementation of a Clinical Practice Guideline for diabetic ketoacidosis at a tertiary pediatric hospital: a
Ana Laura Fustiñana1, Julia Rocío Echeveste1, Julieta Pedalino1
1Hospital de Pediatría "Prof. Dr. J. P. Garrahan", Ciudad Autónoma de Buenos Aires, Argentina.
Insights
Implementing clinical practice guidelines for diabetic ketoacidosis (DKA) in children led to longer treatment durations but reduced key risk factors for cerebral edema (CE). This study highlights a trade-off in DKA management strategies.
Area of Science:
- Pediatric Endocrinology
- Critical Care Medicine
- Clinical Practice Guidelines
Background:
- Diabetic ketoacidosis (DKA) is a severe complication in pediatric diabetes, with cerebral edema (CE) being a primary cause of mortality.
- Standardized treatment protocols aim to mitigate the risks associated with DKA and CE.
Purpose of the Study:
- To evaluate the impact of clinical practice guidelines (CPGs) on DKA episode duration and the incidence of CE risk factors in pediatric patients.
- To compare outcomes before and after the implementation of CPGs for DKA management.
Main Methods:
- A before-and-after study design compared pediatric DKA patients (<18 years) admitted between 2017-2018 (PRE-CPG) and 2021-2022 (CPG).
- Data collected included demographics, clinical and laboratory variables, DKA duration, and CE risk factors (early insulin, bicarbonate use).
- Survival analysis and Cox proportional hazards modeling were used to analyze the data.
Main Results:
- The CPG group had a higher proportion of new-onset diabetes (70% vs. 34%).
- DKA episodes were longer in the CPG group (14h vs. 9.8h, p=0.01), with slower resolution (HR 0.62, p=0.017).
- The CPG group showed significantly less early insulin administration (7% vs. 57%, p<0.01) and bicarbonate use (1% vs. 8%, p=0.037).
Conclusions:
- Implementation of CPGs for pediatric DKA was associated with prolonged episode duration.
- CPGs led to a reduction in specific treatment-related risk factors for CE, namely early insulin administration and bicarbonate use.
Abstract:
Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in pediatric diabetes, mainly due to cerebral edema (CE). Standardized treatment reduces the risk of CE.
Objective:
To compare the duration of DKA episodes and risk factors for CE after implementing clinical practice guidelines (CPGs).
Patients And Method:
A before-and-after study was conducted in children aged < 18 years with DKA admitted to the Emergency Department between 01/01/2017-12/31/2018 (PRE- CPG) and 01/01/2021-12/31/2022 (CPG). Patients with comorbidities were excluded. Demographic, clinical, laboratory, and treatment variables were recorded, as well as DKA episode duration and CE risk factors (early insulin administration within the first hour and use of bicarbonate for correction). Survival analysis and Cox proportional hazards modeling were performed, reporting hazard ratios (HR) and 95% confidence intervals (95% CI).
Results:
A total of 76 children in PRE-CPG and 71 in CPG were included. The CPG group showed a higher proportion of diabetic onset (70% vs. 34%, p < 0.01). Episode duration was longer in the CPG group than the PRE-CPG one (14 h [IQR 9.520] vs. 9.8 h [IQR 5.3-12.5]; p = 0.01, respectively). The resolution curve was faster in the PRE-CPG group (HR 0.62; 95% CI 0.43-0.90; p = 0.017). Compared with the PRE-CPG group, the CPG one showed lower insulin administration in the first hour (7% vs. 57%, p < 0.01) and lower bicarbonate use (1% vs. 8%, p = 0.037).
Conclusions:
The implementation of the CPG was associated with longer DKA episodes and a reduction in treatment-related CE risk factors, such as early insulin administration and bicarbonate use.
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