Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments

ABSTRACTObjectiveDiabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences.MethodsPediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema.ResultsResponses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5–20 mL/kg) and length of time boluses should be administered (20–120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration.ConclusionsThis is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

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Pediatric Diabetic Ketoacidosis and Hypoglycemia

10.2310/em.4413 ◽

2020 ◽

Author(s):

Rachel J Williams ◽

Samantha L. Wood

Keyword(s):

Emergency Department ◽

Key Words ◽

Diabetic Ketoacidosis ◽

Critically Ill ◽

Cerebral Edema ◽

Critically Ill Patients ◽

Pediatric Patients ◽

Serum Glucose ◽

Neurologic Function ◽

Threat To Life

Abnormalities of serum glucose in pediatric patients are commonly encountered in the emergency department and represent an acute threat to life and neurologic function. Rapidly identifying and aggressively treating hyperglycemia with diabetic ketoacidosis and hypoglycemia are critical to ensure the best possible outcome. This review will guide the emergency provider in the identification, resuscitation, workup, and disposition of these critically ill patients. This review contains 6 figures, 13 tables, and 50 reviews. Key Words: Cerebral edema, diabetic ketoacidosis, hyperglycemia, hypoglycemia

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Identifying risk factors for development of diabetic ketoacidosis in type 1 diabetes mellitus

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20185521 ◽

2019 ◽

Vol 6 (2) ◽

pp. 769

Author(s):

G. Anand Kumar ◽

Rajendran . ◽

Swaminathan .

Keyword(s):

Diabetes Mellitus ◽

Risk Factors ◽

Diabetic Ketoacidosis ◽

Tertiary Care ◽

Treatment Protocol ◽

First Episode ◽

Treatment Protocols ◽

Type1 Diabetes ◽

Type1 Diabetes Mellitus

Background: DKA [ Diabetic keto acidosis] It is the commonest cause of diabetes-related death in children. Children with diabetic ketoacidosis at diagnosis have poorer glycemic control, to identify the risk factors for the development of Diabetic Ketoacidosis in Type1 Diabetes Mellitus in a tertiary care center.Methods: The study was conducted in Kovai Medical Centre And Hospital Coimbatore in 2018.22 children were included in present study. Each consultant followed different standard DKA treatment protocols. The two protocols used were Milwaukee and BSPED guidelines.Results: Among the 22 children, 3 children (13%) had recurrent DKA (>1 episode). One child had his third episode and the rest 2 children had their second episode.19 children had their first episode of DKA.Conclusions: There was no death among the 22 children treated. This was because of the care is given by the team of doctors and adherence to treatment protocol (Milwaukee or BSPED) of DKA.

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Treatment Algorithms in Critical Care: Do They Improve Outcomes?

Journal of Pharmacy Practice ◽

10.1177/0897190009356555 ◽

2010 ◽

Vol 23 (1) ◽

pp. 61-68 ◽

Cited By ~ 3

Author(s):

Stephen W. Nissen ◽

Keith M. Olsen

Keyword(s):

Critical Care ◽

Treatment Guidelines ◽

Medical Center ◽

Treatment Guideline ◽

Treatment Protocol ◽

Clinical Trial Data ◽

Critically Ill Patient ◽

Successful Implementation ◽

Treatment Protocols ◽

Order Form

Patients admitted to the intensive care unit (ICU) often have significant underlying morbidities that require complex treatment plans. Because of these complexities, numerous guidelines have been developed to facilitate the management of the critically ill patient. Some of these guidelines include sepsis, community-acquired and ventilator-associated pneumonia, sedation, and glycemic control. Once guidelines are written, a treatment protocol must be developed and implemented within the critical care unit. Our medical center has implemented multiple treatment protocols, often with preprinted order sets with various degrees of success. In 2003, we implemented and later evaluated a sedation order form and protocol. Patients whose sedation was initiated with a standardized order form had more frequent sedation score assessment, less time between sedation vacations, reduced ICU length of ICU stay, and a trend in reduction of ventilator days. However, only 37% of eligible patients were treated using the order form and the protocol, despite the potentially beneficial effects. Some recommendations within guidelines are based on sound clinical evidence supported by randomized controlled trials, although others are based on expert opinion only. The most often-cited reason for protocol noncompliance is disagreement with the published clinical trial data. This paper examines both infectious and noninfectious treatment guidelines and the supportive evidence that they improved patient outcomes. In addition, strategies for successful implementation of a treatment guideline are discussed for clinicians to follow in order to maximize clinical outcomes.

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FATAL CEREBRAL (EDEMA WITH INSULITIS IN DIABETIC KETOACIDOSIS

The Medical Journal of Australia ◽

10.5694/j.1326-5377.1973.tb129825.x ◽

1973 ◽

Vol 2 (20) ◽

pp. 934-937 ◽

Cited By ~ 11

Author(s):

G. L. Warne

Keyword(s):

Diabetic Ketoacidosis ◽

Cerebral Edema

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Antimicrobial resistance in Neisseria gonorrhoeae isolates and gonorrhoea treatment in the Republic of Belarus, Eastern Europe, 2009–2019

BMC Infectious Diseases ◽

10.1186/s12879-021-06184-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Aliaksandra Aniskevich ◽

Iryna Shimanskaya ◽

Iryna Boiko ◽

Tatyana Golubovskaya ◽

Daniel Golparian ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Neisseria Gonorrhoeae ◽

Eastern Europe ◽

Treatment Guidelines ◽

Statistical Significance ◽

Antimicrobial Treatment ◽

National Guidelines ◽

First Line ◽

Exact Test ◽

The Republic

Abstract Background Limited antimicrobial resistance (AMR) data for Neisseria gonorrhoeae are available in Eastern Europe. We investigated AMR in N. gonorrhoeae isolates in the Republic of Belarus from 2009 to 2019, antimicrobial treatment recommended nationally, and treatment given to patients with gonorrhoea. Methods N. gonorrhoeae isolates (n = 522) cultured in three regions of Belarus in 2009–2019 were examined. Determination of minimum inhibitory concentrations (MICs) of eight antimicrobials was performed using Etest. Resistance breakpoints from the European Committee on Antimicrobial Susceptibility Testing were applied where available. A Nitrocefin test identified β-lactamase production. Gonorrhoea treatment for 1652 patients was also analysed. Statistical significance was determined by the Z-test, Fisher’s exact test, or Mann-Whitney U test with p-values of < 0.05 indicating significance. Results In total, 27.8% of the N. gonorrhoeae isolates were resistant to tetracycline, 24.7% to ciprofloxacin, 7.0% to benzylpenicillin, 2.7% to cefixime, and 0.8% to azithromycin. No isolates were resistant to ceftriaxone, spectinomycin, or gentamicin. However, 14 (2.7%) isolates had a ceftriaxone MIC of 0.125 mg/L, exactly at the resistance breakpoint (MIC > 0.125 mg/L). Only one (0.2%) isolate, from 2013, produced β-lactamase. From 2009 to 2019, the levels of resistance to ciprofloxacin and tetracycline were relatively high and stable. Resistance to cefixime was not identified before 2013 but peaked at 22.2% in 2017. Only sporadic isolates with resistance to azithromycin were found in 2009 (n = 1), 2012 (n = 1), and 2018–2019 (n = 2). Overall, 862 (52.2%) patients received first-line treatment according to national guidelines (ceftriaxone 1 g). However, 154 (9.3%) patients received a nationally recommended alternative treatment (cefixime 400 mg or ofloxacin 400 mg), and 636 (38.5%) were given non-recommended treatment. Conclusions The gonococcal resistance to ciprofloxacin and tetracycline was high, however, the resistance to azithromycin was low and no resistance to ceftriaxone was identified. Ceftriaxone 1 g can continuously be recommended as empiric first-line gonorrhoea therapy in Belarus. Fluoroquinolones should not be prescribed for treatment if susceptibility has not been confirmed by testing. Timely updating and high compliance with national evidence-based gonorrhoea treatment guidelines based on quality-assured AMR data are imperative. The need for continued, improved and enhanced surveillance of gonococcal AMR in Belarus is evident.

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Cerebrovascular complications of diabetic ketoacidosis in children

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302011000400009 ◽

2011 ◽

Vol 55 (4) ◽

pp. 288-290 ◽

Cited By ~ 7

Author(s):

Luis Felipe Mendonça de Siqueira

Keyword(s):

Diabetic Ketoacidosis ◽

Cerebral Edema ◽

Neurological Complications ◽

Neurological Deterioration ◽

Cerebrovascular Complications

Neurological deterioration in children with diabetic ketoacidosis (DKA) is commonly caused by cerebral edema. However, subtle cerebral injuries including strokes should also be suspected, since children with hyperglycemia and DKA are prone to thrombosis. In this paper, a case involving a 2 month-old patient that presented cerebral edema and stroke as complications of DKA is reported. In the discussion, the literature on neurological complications of DKA in children is briefly reviewed, emphasizing the prothrombotic tendency of these patients.

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A RARE CASE MORTALITY OF DIABETIC KETOACIDOSIS- CEREBRAL EDEMA WITH TONSILLAR HERNIATION- A CONTRADICTORY OPINION.IS SODIUM BICARBONATE A REAL CULPRIT?

10.36106/1503265 ◽

2021 ◽

pp. 8-10

Author(s):

Sruthi P ◽

Manzoor Sharieff M ◽

Prasanth Kumar P ◽

Vishnu priya V ◽

Nagarajan N ◽

...

Keyword(s):

Diabetic Ketoacidosis ◽

Cerebral Edema ◽

Hydrogen Exchange ◽

Ketone Bodies ◽

Acetoacetic Acid ◽

Tonsillar Herniation ◽

Sodium Hydrogen ◽

Uncontrolled Diabetes ◽

Case Mortality

Diabetic ketoacidosis (DKA) is the most common complication seen in uncontrolled diabetes mellitus. DKA is most commonly seen with patients of type 1 diabetes. Depletion of Insulin leads to high blood sugars which in turn leads osmotic diuresis, production of ketone bodies i.e, βhydroxybutyric acid and acetoacetic acid, dysregulation of sodium hydrogen exchange mechanism[2]. As a consequence to the above stated mechanisms, cerebral edema has been documented as a fatal complication in DKA. Mortality documented due to cerebral edema is 21-25%[4].

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