Keywords
type one diabetes mellitus - diabetic ketoacidosis - pediatric residents - knowledge
- residents - training - education
Introduction
Diabetes mellitus is a group of diseases characterized by abnormally high blood glucose
levels. Type one diabetes mellitus (T1DM) accounts for around 10% of all cases of
diabetes across all age groups, but it accounts for more than 90% of diabetes mellitus
in children.[1] It is an autoimmune disease resulting from cellular dysfunction of pancreatic β-cells
affecting its ability to produce enough insulin that is required to maintain a stable
blood glucose level.[2] Globally, the incidence of T1DM is 15 per 100,000 people and the prevalence is 9.5%.[3] Most recently, the 10th edition (2021) of the International Diabetes Federation
(IDF) atlas reported that diabetes is rapidly growing worldwide, with the highest
incidence rate of T1DM in children between 0 and 14 years old in Finland and Sweden
with 52.2 and 44.1 per 100,000 population per year followed by Kuwait and Qatar 41.7
and 38.1 per 100,000 population per year, respectively,[4] whereas the incidence rate of T1DM in Oman among the pediatric age is 2.5 per 100,000.[5] The frequency of DKA as a first presentation of T1DM varies from 15 to 67% in various
studies.[6] It was reported to be 33.6% in Kuwait,[7] 44.9% in Saudi Arabia,[8] and 31% in Oman.[9]
Diabetic ketoacidosis (DKA) is a common and life-threatening complication of T1DM,
resulting from an insulin deficiency and an increase in other counter-regulatory hormones.
This would enhance the hepatic production of glucose and increase fat catabolism leading
to high levels of ketones and metabolic acidosis. The overall mortality rate of DKA
in Arab countries was not thoroughly studied and published; however, according to
the available literature, it ranges between 0.21% and 12.9%.[10] Cerebral edema (CE) is one of the major and serious complications that can be associated
with inappropriate management of DKA. Different factors may play a role in the development
of CE such as high serum urea, hypocapnia, and hyponatremia.[11]
Although DKA is a commonly encountered medical case, unfortunately, medical errors
in its management still occur leading to significant mortality and morbidity.[12] Variable protocols had been used in different institutions and specialties including
emergency departments, general wards, and intensive units. These nonunified protocols
could sometime be leading to controversies to obtain optimal management and sometimes
they could lead to an increase in the risk of some complications such as CE.[13] A study was conducted in 1997 to compare different DKA management strategies among
physicians from different specialties including emergency physicians, endocrinologists,
pediatric residents, and general pediatricians. Significant differences in the approach
and management of DKA among different specialties were shown.[14] That pointed toward the importance of having a unified protocol for the management
of DKA that helps in improving the quality of care and minimizing errors and thereby
reducing the mortality and morbidity associated with DKA and its management. That
has also driven scientific societies and institutions to standardize their protocols
in the management of DKA when possible. Once that was achieved, the next step was
to make sure that treating doctors are aware of these updated guidelines. Especially
when it is not uncommon that junior members of variable admitting teams initiate the
management of those patients presenting with DKA without involving pediatric diabetic
specialist teams (DST). For that, our study was conducted to assess the knowledge
and the confidence of Omani pediatric residents in the recognition and appropriate
management of DKA to identify any gaps in knowledge that we could work on to minimize
medical errors and improve overall patients care in Oman. The findings of our study
were made comparable to similar and recently published work from Iraq and Bahrain.
The pediatric residency program in Oman is a 4-year program that starts after the
successful completion of an internship year. Residents have a weekly educational half-day
and throughout their program, they have access to several workshops and educational
activities such as grand rounds, registrar quizzes, and journal clubs. Additionally,
pediatric residents in Oman have an informal pediatric study group on social media
that is managed voluntarily by a group of pediatricians from different specialties
that enables them to discuss a variety of cases daily.
Materials and Methods
Our study is a cross-sectional study that included all pediatric residents enrolled
with the Oman Medical Specialties Board (OMSB), from year 1 to year 4 of residency
in 2021. Data were collected by using an online survey distributed among pediatric
residents in OMSB. The questionnaire was originally developed, validated, and cascaded
by a group of pediatric endocrinologists from Iraq and Bahrain. We adopted the same
questionnaire, and the knowledge questions were mainly based on the 2020 DKA management
guideline from the British Society of Pediatric Endocrinology and Diabetes (BSPED).
It contains 30 questions, the first part of which assessed the resident's general
knowledge of DKA and its diagnostic criteria. The second part of the questionnaire
evaluated residents' knowledge about four main domains in DKA management including
(1) fluid management, (2) insulin therapy, (3) treatment monitoring, and (4) involvement
of a senior physician. The third part was to evaluate their overall confidence using
the Likert scale and their willingness to have extra sessions or workshops. The questions
were directed toward clear points in the assessment and management of DKA, avoiding
any controversial issues.
Data Analysis
All data were collected using Survey Monkey, a commercial online Web site. Data were
analyzed using the SPSS program. Statistical significance was considered when p-value was <0.05.
Results
In total, 69 pediatric residents (15M:54F) out of 84 had responded to the survey,
giving a response rate of 82%, more than the received responses from the Bahraini
and Iraqi residents (42 and 41 responses, respectively). More than half of our responders
were junior residents R1 and R2 (59.3%). Among involved residents, 10.1% did not complete
any emergency block during their training so far, 34.8% completed two blocks, and
42% completed more than four blocks. Each block of training is 4 weeks in duration.
The number of DKA cases managed by the majority of residents (65%) is around five
cases during their training at the time of responding to our questionnaire. None of
the responded residents is diagnosed with diabetes mellitus. The rationale for mentioning
this is we would have excluded their responses from our analysis to avoid any bias
since the person who lives with diabetes is has more exposure to the condition which
probably gives higher knowledge about diabetes and DKA compared with the others. [Table 1] shows the characteristics of the responded residents.
Table 1
Participant characteristics
|
Characteristics
|
Value
|
Percent%
|
|
Gender
|
|
Male
|
15
|
21.7
|
|
Female
|
54
|
78.3
|
|
Residency level
|
|
1
|
24
|
34.8
|
|
2
|
17
|
24.6
|
|
3
|
16
|
23.2
|
|
4
|
12
|
17.4
|
|
Number of completed emergency blocks
|
|
0
|
7
|
10.1
|
|
1
|
3
|
4.3
|
|
2
|
24
|
34.8
|
|
3
|
6
|
8.7
|
|
≥4
|
29
|
42
|
|
Diabetes Miletus among residents
|
|
Yes
|
0
|
0
|
|
No
|
69
|
100
|
|
Initial self-assessment and rating
|
|
Very good
|
7
|
10.1
|
|
Good
|
39
|
56.5
|
|
Fair
|
21
|
30.4
|
|
Not sure, I don't know
|
2
|
2.9
|
|
Number of DKA cases managed by residents
|
|
None
|
7
|
10.1
|
|
< 5
|
45
|
65.2
|
|
5–10
|
16
|
23.2
|
|
> 10
|
1
|
1.4
|
Two clinical scenarios were provided, to assess the ability of residents to recognize
the clinical features of DKA. The percentage of correct answers among candidates was
92.8%, in which 96.9% of senior residents (R3–R4) and 89.9% of junior residents (R1–R2)
were able to identify the correct answer. In total, 92.7% of senior residents (R3–R4)
and 88.7% of junior residents (R1–R2) were able to identify the correct biochemical
criteria to diagnose DKA. Surprisingly, the DKA severity classification was answered
correctly only by 65.6% of senior residents compared with 79.6% of junior residents.
[Table 2] shows a comparison of the received responses according to the training level.
Table 2
Comparison of the received responses according to the training level
|
Questions
|
Percentage of correct answers among resident
|
Residency level
|
Junior resident
(R1 + R2)
N = 41
|
Senior residents
(R3-R4)
N = 28
|
p-Value
|
|
R1
N:24
|
R2
N:17
|
R3
N:16
|
R4
N:12
|
Between (R1–2) vs. R3–4s
|
|
DKA diagnosis and severity classification
|
|
Clinical features of DKA
|
92.8%
|
91.6%
|
88.2%
|
93.8%
|
100%
|
89.9%
|
96.9%
|
0.332
|
|
Biochemical criteria for DKA diagnosis
|
89.9%
|
83.3%
|
94.1%
|
93.8%
|
91.7%
|
88.7%
|
92.7%
|
0.496
|
|
Determining the severity of DKA
|
72.5%
|
83.3%
|
70.6%
|
56.3%
|
75%
|
76.9%
|
65.6%
|
0.205
|
|
Fluid management
|
|
Type of initial fluid in DKA management
|
27.5%
|
29.1%
|
23.5%
|
31.3%
|
25%
|
26.3%
|
28.3%
|
0.872
|
|
Amount of initial bolus in severe DKA without shock
|
79.7%
|
66.7%
|
88.2%
|
81.3%
|
91.7%
|
77.4%
|
86.5%
|
0.423
|
|
Amount of initial fluid bolus in DKA with shock
|
58%
|
62.5%
|
58.9%
|
56.3%
|
50%
|
60.7%
|
53.1%
|
0.541
|
|
The rate of fluid infusion
|
71%
|
70.8%
|
64.7%
|
75%
|
75%
|
67.7%
|
75%
|
0.548
|
|
Indication of adding dextrose to IV fluid
|
89.9%
|
87.5%
|
82.4%
|
87.5%
|
75%
|
84.9%
|
81.2%
|
0.718
|
|
Monitoring
|
|
Parameters need to be monitor during DKA management
|
89.9%
|
83.3%
|
88.2%
|
100%
|
91.7%
|
85.7%
|
95.8%
|
0.136
|
|
Frequency of Glucose monitoring
|
75.4%
|
79.2%
|
76.5%
|
68.8%
|
75%
|
77.8%
|
71.9
|
0.528
|
|
frequency of cardiac monitoring
|
92.8%
|
91.7%
|
82.4%
|
93.8%
|
100%
|
87%
|
96.9%
|
0.211
|
|
Complication
|
|
Awareness of sign and symptoms of cerebral edema
|
94.2%
|
95.8%
|
94.1%
|
93.8%
|
91.7%
|
94.9%
|
92.7%
|
0.689
|
|
Dealing with hypoglycemia
|
56.5%
|
45.8%
|
64.7%
|
56.3%
|
66.7%
|
55.2%
|
61.5%
|
0.703
|
|
Awareness of Electrolytes disturbance in DKA
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
–
|
|
Insulin therapy
|
|
Timing for starting insulin infusion
|
88.4%
|
91.7%
|
82.4%
|
100%
|
75%
|
87%
|
87.5%
|
0.849
|
|
Switching from IV to SC insulin
|
84.1%
|
70.8%
|
94.1%
|
81.3%
|
100%
|
82.4%
|
90.6%
|
0.459
|
|
Others
|
|
Avoiding use of sodium bicarbonate in DKA management
|
94.2%
|
95.8%
|
88.2%
|
100%
|
91.7%
|
92%
|
95.8%
|
0.515
|
|
Notifying senior immediately
|
75.4%
|
91.7%
|
76.5%
|
75%
|
41.6%
|
84.1%
|
58.3%
|
0.018
|
Abbreviations: DKA, diabetic ketoacidosis; IV, intravenous; SC, subcutaneous.
Five questions were provided to assess the knowledge of the trainees in fluid management
of patients presenting with DKA. Unfortunately, only 27.5% of residents chose the
correct type of initial intravenous fluid recommended to be used in DKA. As shown
in [Table 2], the highest percentage of correct answers was among R3 (31.3%) followed by R1 (29.1%)
and R4 (25%) and R2 (23.5%). The second question was about the amount of initial bolus
in severe DKA in a patient presenting without a shock and it was answered correctly
by 79.7% of residents. The highest percentage (91.7%) was in R4 and the lowest was
in R1 (66.7%). The third question was about the amount and rate of fluid correction
in patients with DKA found to be in a shock, 57.9% chose to give fast and full fluid
bolus while 42.03% of residents preferred to give half fluid bolus over 30 to 60 minutes.
The fourth question was about the rate of fluid maintenance, 71% of trainees were
aware of the correct equation used to calculate the intravenous fluids over 48 hours.
The majority of this cohort (89.9%) decided to add glucose to the running fluid when
blood glucose drops below 14 mmol/L during acute management of DKA.
Regarding the timing of starting insulin therapy, 88.4% of the residents would initiate
insulin therapy after 60 minutes from starting the intravenous fluids. However, 10.1%
of the trainees choose to start insulin as soon as they made the DKA diagnosis. In
total, 90.6% of senior residents (R3–R4) and 82.4% of junior residents (R1–R2) recognized
the correct criteria to switch from intravenous to subcutaneous insulin.
Most of the trainees, 89.9% were aware of the important parameters that need frequent
monitoring during DKA management. In total, 92.8% of residents would like to do cardiac
monitoring every 2 to 4 hours; however, only 75.4% of them want to check blood glucose
level hourly, whereas 18.8% of residents will check it every 2 hours ([Table 2]).
Three questions were provided to assess the knowledge of the residents approximately
four main complications of DKA including CE, hypoglycemia, electrolyte disturbances,
and arrhythmia. In total, 94.4% of this cohort would inform their senior immediately
if a patient with DKA developed a headache reflecting their awareness about symptoms
of CE. On the contrary, there were variations in the trainee's management plan of
hypoglycemia during DKA management, 55.1% of them will increase the dextrose concentration
in intravenous fluid, 11.9% will give a bolus of 10% dextrose, 7.25% prefer to stop
insulin temporarily, while 21.7% chose to stop insulin temporarily, give a bolus,
and increase the dextrosity of the fluids. Almost all residents were aware that cardiac
arrhythmia could result from a disturbance in potassium level during DKA, and most
of them (97.8%) thought hypokalemia is the main cause of arrhythmia in DKA.
In total, 91.7% of 1st-year residents and 76.5% of the 2nd-year residents would involve
their senior immediately as soon as they diagnosed pediatric patient with DKA, compared
with 41.6% of 4th-year residents. However, 25% of residents in their fourth year of
training choose to inform seniors after giving the first fluid bolus and 25% will
involve seniors only once it is becoming difficult to manage.
[Table 3] showed a comparison in responses regarding timing of endocrine consultations among
residents at different training levels. In total, 70.7% of junior residents and 71.4%
of senior residents prefer to consult an endocrinologist while the patient is still
in the emergency room, and 7.3% of junior residents and 14.3% of senior residents
would consult endocrine on-call within 2 hours of admitting the child. However, 7.3%
of junior residents and 33.6% of senior residents would involve endocrinologists only
if the child required intubation and PICU admission. The rest of the residents were
not sure when to consult the on-call pediatric endocrinologist.
Table 3
Comparison in response regarding timing of endocrine consultations among residents
at different training levels
|
Timing of notifying endocrinologist
|
R1
|
R2
|
R3
|
R4
|
Junior R1–R2
|
Senior R3–R4
|
|
While the patient still in emergency room
|
16(66.7%)
|
13(76.5%)
|
10 (62.5%)
|
10 (83.3%)
|
29 (70.7%)
|
20 (71.4%)
|
|
Within 2 h of admitting the child
|
2 (8.3%)
|
1 (5.88%)
|
3 (18.75%)
|
1 (8.33%)
|
3 (7.3%)
|
4 (14.3%)
|
|
Only if the child had required PICU admission
|
3(12.5%)
|
0
|
0
|
1 (8.33%)
|
3 (7.3%)
|
1 (3.6%)
|
|
Not sure
|
3 (12.5)
|
3 (17.6%)
|
3 (18.75%)
|
0
|
6(14.6%)
|
3 (10.7%)
|
Abbreviations: PICU, pediatric intensive care unit.
The majority of the residents (88.4%) feel they need extra teaching sessions to improve
their knowledge and confidence in DKA management.
Discussion
DKA remains the most common cause of death in children and adolescents with T1DM.
CE, the serious complication of DKA, is the most frequent cause of death in DKA. CE
usually develops after 4 to 12 hours from initiation of fluid therapy. Since DKA is
one of not uncommon emergency conditions. Therefore, we aimed to assess the knowledge
of our frontline junior doctors by conducting this cross-sectional study. Our study
enrolled 69 out of 84 residents with a very good response rate. In total, 45 and 70
residents from Bahrain and Iraq, respectively, previously responded to the same questionnaire,
for which we are making a comparison.[15]
[16] The knowledge of our residents regarding the clinical features, biochemical criteria,
and DKA severity grading was sufficient, with no significant difference between different
training levels. In our study, 88.7% of junior residents (R1–R2) and 92.7% of senior
residents (R3–R4) were able to correctly identify the biochemical criteria to diagnose
DKA based on BSPED guidelines (hyperglycemia with blood glucose >11 mmol/L, venous
pH < 7.3 or serum bicarbonate <15 mmol/L with ketonemia >3mmol/L or ketonuria ++),
this percentage was much higher compared with the study done among Bahrani and Iraqi
residents. Ali et al found that 65 and 86.4% of R1-R3 and R4, respectively, were able
to correctly diagnose DKA, whereas a lower rate was observed among the Iraqi residents
where only 20.7% of R1-R3 and 45.5% of R4 could correctly identify the diagnostic
criteria of DKA.
Generally, the awareness regarding DKA management was adequate; however, the area
with the lowest score was related to fluid management, which is one of the most important
aspects of DKA management. Our results showed residents were aware of the amount of
fluid used for resuscitation, the equation of calculating the rate of maintenance
fluid and indications of adding dextrose to the infused intravenous fluid with a percentages
of correct answers ranging between 60–80%. Surprisingly the main gap in knowledge
was identifying the correct type of initial intravenous maintenance fluid, only 27%
of residents got the correct answer (0.9% saline and 20 mmol potassium chloride in
500 mL bag) with no significant difference among different trainees' levels. Most
of the residents (68.1%) choose to give normal saline without adding potassium to
it. One possible explanation for their answer is that they prefer to wait for the
laboratory results to know the exact level of serum potassium before adding potassium
chloride to the infused fluids, although all guidelines recommend adding potassium
to the infused fluid and then adjusting the amount of potassium concentration according
to the serum potassium level unless the patient is hyperkalemic.[17]
[18] These results were in line with the findings from the other studies that we are
comparing with.
Another major deficit in knowledge was noticed in the ability of residents to deal
with hypoglycemia during DKA management, while the acidosis was still not corrected.
The percentage of correct answers among junior residents was 55.2% and senior residents
61.5% with no statical significance between different training levels. Although our
local protocols clearly recommend avoiding stopping insulin infusion if biochemical
markers of DKA (venous pH, anion gap, ketones) have not normalized, 7.25% of residents
prefer to stop insulin temporarily. Similar results with even much lower awareness
were found in the Bahrani study.[15] This might reflect the lack of awareness of the importance of insulin therapy not
only for normalizing blood glucose but rather for restoring normal cellular metabolism,
to suppressing lipolysis and ketogenesis.
Our study revealed that residents in different training levels have adequate knowledge
about the correct timing of initiation of insulin infusion and the criteria for switching
from intravenous to subcutaneous insulin. These results were relatively like the other
results from the other studies that we are comparing with. More than 94% of our residents
were aware of the recent guidelines that discourage the use of sodium bicarbonate
during DKA management due to the increased risk of CE, compared with 92 and 88% of
Iraqi and Bahraini residents, respectively.
The overall confidence of residents in managing a patient with DKA ranged from fair
to confident on the Likert scale, and it was directly proportional to residency level.
In total, 33.33% of R4 felt they have a “fair” confidence level in managing DKA, while
58.33% of them were “confident” and 8.33% were “very confident.” However, 11.67% of
2nd-year residents were not confident at all in managing DKA. Similarly, the result
of the initial self-assessment and rating ranged from “poor/not sure” to “very good,”
showing that most of the residents rated themselves between “fair” and “good.” In
total, 41.67% of 4th-year residency level rated themselves as “very good” and 14.67%
rated themselves as “good.” In comparison to the 1st-year residents, more than half
rated themselves as “good” (58.33%) and 37.5% as “fair.” These results reflect their
response on timing to involve their seniors, 91.7% of the 1st-year residents and 75%
of 2nd-year residents would involve their senior immediately as soon as they diagnose
a patient with DKA, compared with 41.6% of the 4th-year residents. A quarter of the
4th-year residents would choose to inform their seniors after giving the first fluid
bolus and the other quarter of them would involve seniors only once it is difficult
to manage. Similar results were found in the Bahrani study, most of 1st-year residents
prefer to call a senior doctor immediately, while 45.4% of 4th-year residents would
only involve seniors when they face difficulty in the management. Although the British
Society of Pediatric Endocrine and Diabetes recommended consulting a more senior doctor
on-call as soon as a case of DKA is suspected as the patient can deteriorate very
quickly.[16]
[Table 3] showed the response of participants regarding when to consult endocrinologists,
most of the residents from different residency levels prefer to involve endocrinologists
while the patient is still in the emergency room. However, 14.6% of junior residents
and 10.7% of senior residents were not sure when to inform the endocrinologist. This
question was more of exploratory as there was no clear consensus and recommendation
for the timing of when to consult the pediatric endocrinologist/diabetologist. Although
Joint British Diabetes Societies highly recommended to involve DST during the acute
phase of DKA and patient should not be discharged home before being reviewed by the
specialized team as it would improve management outcomes, shorten the duration of
stay in the hospital, and optimize patient safety.[19]
The overall assessment and scoring of our residents revealed that 36.2% of residents
answer around 50 to 75% of questions correctly, 23% of them got 80 to 90% score of
correct answers, and only 1.4% of residents got more than 95% correct answers ([Fig. 1]). Generally, the knowledge and awareness of our trainees was better compared with
the recently published studies from Bahrain and Iraq. This might reflect the benefit
of the formal and nonformal academic teachings of Omani residents that includes frequent
assessments and evaluations of residents with encouragement to read more and be updated
about the new guidelines. Nevertheless, more comprehensive teaching and workshops
with variable clinical scenarios are needed to make sure that residents can deal with
DKA and its possible complications appropriately without making any mistakes.
Fig. 1 Overall performance score among different training levels.
One of the limitations of our study is that the questionnaire was distributed to the
residents without monitoring the time used for answering the questions that limited
their access to online or hard copy resources that might use to help them in answering
the questions, which might result in false high scoring. Saying that, in practice,
doctors are not prohibited to use any available online source of guideline to manage
DKA as far as this guideline is endorsed by a recognized authority, group, or society.
Conclusion
The overall knowledge and confidence of the Omani pediatric residents were satisfying.
However, there are still some gaps in knowledge to be bridged about the management
of pediatric DKA. Continuous educational activities are desired. Therefore, more sessions
about DKA management are to be scheduled and perhaps applying some simulation training
to boost their knowledge and confidence.
