Implementation of an Intravenous Fluid Titration Algorithm to Treat Pediatric Diabetic Ketoacidosis

Abstract

Diabetic ketoacidosis (DKA) is a common cause of admission to the pediatric intensive care unit and many centers utilize the “two-bag system” to treat DKA. We developed an intravenous fluid (IVF) titration algorithm to standardize adjustments of the two bags. A retrospective cohort study was performed comparing 155 patients treated before and 175 patients treated after implementation of the IVF titration algorithm. Postimplementation patients reached the blood glucose target zone faster and had a higher probability of remaining at goal while on insulin infusion. There was no significant difference in incidence of cerebral edema or hypoglycemia between study groups. Overall IVF titration algorithm compliance was 95%. Implementation of an IVF titration algorithm is safe and effective when treating DKA in children.

Keywords

diabetes - insulin - ketoacidosis

Publikationsverlauf

Eingereicht: 10. Februar 2020

Angenommen: 23. April 2020

Artikel online veröffentlicht:
04. Juni 2020

• References

• 1 Lévy-Marchal C, Patterson CC, Green A. EURODIAB ACE Study Group, Europe and Diabetes. Geographical variation of presentation at diagnosis of type I diabetes in children: the EURODIAB study. European and Diabetes. Diabetologia 2001; 44 (Suppl. 03) B75-B80
• 2 Hanas R, Lindgren F, Lindblad B. Diabetic ketoacidosis and cerebral oedema in Sweden--a 2-year paediatric population study. Diabet Med 2007; 24 (10) 1080-1085
• 3 Rodacki M, Pereira JRD, Nabuco de Oliveira AM. et al. Ethnicity and young age influence the frequency of diabetic ketoacidosis at the onset of type 1 diabetes. Diabetes Res Clin Pract 2007; 78 (02) 259-262
• 4 Rewers A, Klingensmith G, Davis C. et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics 2008; 121 (05) e1258-e1266
• 5 Rewers A, Chase HP, Mackenzie T. et al. Predictors of acute complications in children with type 1 diabetes. JAMA 2002; 287 (19) 2511-2518
• 6 Rosilio M, Cotton JB, Wieliczko MC. et al; French Pediatric Diabetes Group. Factors associated with glycemic control. A cross-sectional nationwide study in 2,579 French children with type 1 diabetes. Diabetes Care 1998; 21 (07) 1146-1153
• 7 Morris AD, Boyle DI, McMahon AD, Greene SA, MacDonald TM, Newton RW. Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. The DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland. Medicines Monitoring Unit. Lancet 1997; 350 (9090): 1505-1510
• 8 Smith CP, Firth D, Bennett S, Howard C, Chisholm P. Ketoacidosis occurring in newly diagnosed and established diabetic children. Acta Paediatr 1998; 87 (05) 537-541
• 9 Umpierrez GE, Kelly JP, Navarrete JE, Casals MM, Kitabchi AE. Hyperglycemic crises in urban blacks. Arch Intern Med 1997; 157 (06) 669-675
• 10 Lawrence SE, Cummings EA, Gaboury I, Daneman D. Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr 2005; 146 (05) 688-692
• 11 Daneman D. Diabetes-related mortality. A pediatrician's view. Diabetes Care 2001; 24 (05) 801-802
• 12 Grimberg A, Cerri RW, Satin-Smith M, Cohen P. The “two bag system” for variable intravenous dextrose and fluid administration: benefits in diabetic ketoacidosis management. J Pediatr 1999; 134 (03) 376-378
• 13 Wolfsdorf JI, Glaser N, Agus M. et al. ISPAD Clinical Practice Consensus Guidelines 2018: diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 (Suppl. 27) 155-177
• 14 Zeitler P, Haqq A, Rosenbloom A, Glaser N. Drugs and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment. J Pediatr 2011; 158 (01) 9-14 , 14.e1–14.e2
• 15 Wetzel RC, Sachedeva R, Rice TB. Are all ICUs the same?. Paediatr Anaesth 2011; 21 (07) 787-793
• 16 Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988; 16 (11) 1110-1116
• 17 The Joint Commission Medication Management. (Updated December 2019). . Available at: https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/medication-management-mm/000002114/. Accessed March 31, 2020
• 18 Agus MS, Wypij D, Hirshberg EL. et al; HALF-PINT Study Investigators and the PALISI Network. Tight glycemic control in critically ill children. N Engl J Med 2017; 376 (08) 729-741
• 19 Agus MS, Steil GM, Wypij D. et al; SPECS Study Investigators. Tight glycemic control versus standard care after pediatric cardiac surgery. N Engl J Med 2012; 367 (13) 1208-1219
• 20 Wolfsdorf JI, Glaser N, Agus M. et al. ISPAD Clinical Practice Consensus Guidelines 2018: diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 (Suppl. 27) 155-177
• 21 Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med 2011; 12 (02) 137-140
• 22 Glaser N. Cerebral injury and cerebral edema in children with diabetic ketoacidosis: could cerebral ischemia and reperfusion injury be involved?. Pediatr Diabetes 2009; 10 (08) 534-541
• 23 Decourcey DD, Steil GM, Wypij D, Agus MS. Increasing use of hypertonic saline over mannitol in the treatment of symptomatic cerebral edema in pediatric diabetic ketoacidosis: an 11-year retrospective analysis of mortality. Pediatr Crit Care Med 2013; 14 (07) 694-700
• 24 Soto-Rivera CL, Asaro LA, Agus MS, DeCourcey DD. Suspected cerebral edema in diabetic ketoacidosis: is there still a role for head CT in treatment decisions?. Pediatr Crit Care Med 2017; 18 (03) 207-212