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Variations in the management of diabetic ketoacidosis in children
1Department of Paediatrics, John Radcliffe Hospital, Oxford, UK.
Insights
Cerebral edema in children treated for diabetic ketoacidosis is a serious concern. Protocols using more aggressive fluid resuscitation and specific saline types were linked to higher incidences of this complication.
Area of Science:
- Pediatric Endocrinology
- Critical Care Medicine
- Neurology
Background:
- Cerebral edema is a significant complication in pediatric diabetic ketoacidosis (DKA).
- Variations in DKA management protocols may influence the occurrence of cerebral edema.
- Understanding these variations is crucial for improving patient outcomes.
Purpose of the Study:
- To investigate the relationship between fluid, bicarbonate, insulin, and potassium management strategies in DKA and the incidence of cerebral edema in UK pediatric centers.
- To identify specific treatment variations associated with recalled cases of cerebral edema.
Main Methods:
- A survey of 25 UK centers examining their DKA management protocols.
- Correlation of fluid resuscitation volumes, fluid types (0.9% saline, 0.45% saline), rehydration periods, and potassium administration with reported cerebral edema incidence.
- Comparison of protocols between centers that recalled cerebral edema cases and those that did not.
Main Results:
- Protocols associated with cerebral edema utilized more plasma for resuscitation (22 vs. 18 ml/kg) and larger maintenance fluid volumes for children aged 6-9 years (81 vs. 70 ml/kg/day).
- Centers reporting cerebral edema were more likely to switch to 0.18% saline after initial glucose reduction compared to those without reported cases (8/8 vs. 5/10).
- Free water overload is suggested as a potential contributing factor to cerebral edema.
Conclusions:
- Specific fluid management strategies, including aggressive resuscitation and certain saline types, may increase the risk of cerebral edema in pediatric DKA.
- Further research into optimal fluid management is warranted to minimize this life-threatening complication.
- Standardizing DKA treatment protocols could potentially reduce the incidence of cerebral edema.
Abstract:
Cerebral oedema which develops during the treatment of diabetic ketoacidosis is an important cause of mortality and morbidity in children. We examined 25 management protocols from throughout the UK and related variations in fluid, bicarbonate, insulin, and potassium regimens to the incidence of cerebral oedema recalled in each centre. Treatment of shock ranged from 5 to 25 (median 20) ml kg-1 plasma (5 recommended 0.9% saline only) over 10-60 min. Subsequent fluid regimens used 0.9% saline in 24 (0.45% saline in 1); 8 used 0.45% saline if hypernatraemia was present. The rehydration period ranged from 24 h (n = 20) to 48 h (n = 1) and was based on steady (n = 12) or irregular (n = 13) replacement. The quantity of potassium added to fluids was 20-80 (median 30) mmol l-1. Eight centres recalled having seen 1-5 (median 2) cases of cerebral oedema in the past 5 yr, 10 centres recalled none. Compared with the 10 centres without cerebral oedema, protocols from the 8 with cerebral oedema used more plasma to resuscitate (22 +/- 3 (mean +/- SD) vs 18 +/- 4 ml kg-1; p < 0.025), suggested larger maintenance fluid volumes for ages 6-9 yr (81 +/- 2 vs 70 +/- 11 ml kg-1 day-1; p < 0.005) and were more likely to change to 0.18% saline when blood glucose had fallen (8/8 vs 5/10) than 0.45% saline (0/8 vs. 5/10; p < 0.05). Free water overload may contribute to cerebral oedema.(ABSTRACT TRUNCATED AT 250 WORDS)