IMPROVING MANAGEMENT
OF DIABETIC KETOACIDOSIS
IN CHILDREN
September 2001
American journal of pediatrics
Eric I.Felner ,MD & Perrin C.White,MD
Department of pediatrics ,division of
endocrinology ,university of texas southwestern medical
center ,texas
ABSTRACT
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OBJECTIVE
To use a simpler method of calculating fluid needs
Use fluids with higher sodium concentration
Allow glucose concentration to be adjusted easily
DESIGN
Compared patients treated with traditional &
revised protocols (220&300 patients
respectively,over consecutive 2.75 yr intervals)
sixty patient records were randomly selected from
the first group(30 treated with each of 2 protocol
versions)
30 from the second group
biochemical & clinical parameters were analyzed
RESULTS
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Patients treated under revised protocol
received less total fluid ,
needed fewer iv fluid changes
Treated at less cost
Resolved acidosis more rapidly
Rate of cerebral edema (0.3-0.5%)was unchanged
METHODS
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All patients received a 20ml/kg bolus infusion of
0.9%NACL for 30-40 min
Later regular human insulin in a pre mixed solution
(0.2u/ml in 0.9% NACL) at a rate of 0.1U/kg/hr IV
Initial IV insulin bolus was not administered
Fluid requirements
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Group 1
fluid deficit was calculated by multiplying % of
dehydration by the patients weight
This fluid deficit was added to 1.5 times the
maintenance rate to determine the patients total
fluid requirement
Half of the total required fluid given in the 1st 12hrs
& remaining 50% over next 24hrs
GROUP 2
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Total fluids were delivered at 2.5 times the
maintenance rate regardless of the dehydration
Fluids were decreased to 1 to 1.5 times the
maintenance rate after 24 hrs of treatment until
urine ketones were negative
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Composition of IV fluids also differed b/w the 2
groups
After initial IV bolus patients in group 1 received
0.45%NACL(1/2ns,75mmol/l Na+)
group 2 received 0.675% NACL
(3/4ns,115.5mmol/l Na+)
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Amount of KCL&K2PO4 used in each group
depended on the initial serum levels of k+ ,po4-,ca2+
But usually totaled 40mmol/l of k+
Patients received k +only after voiding
&confirmation of serum k+ level less than 5.5 mEq/l
K +concentrations were increased if the patient
became hypokalemic
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In group 1a the initial 0.45% NACL solution was
discontinued&replaced with an identical solution
containing an appropriate amount of glucose to
provide a 4:1 glucose to insulin units ratio(512.5g/dl glucose ,D5-D12.5)
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In group1b 10g/dl of glucose (D10) was added to
a separate solution that was other wise identical to
the initial fluid
The rate of infusion of each of the 2 solutions was
varied as necessary to control the level and rate of
decrease of serum glucose with both the insulin &
total fluid delivery remaining constant

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3 separate IV solutions including the insulin solution
(3-bag protocol) were needed for such patients
rather than 2 bags
In group 2 the use of 3 solutions was mandated for
all patients
Nelson
Oski
Rudolph
Gellis&kaga Group1
n
group2
20
10-20
10-20
10-20
20
20
Maintenanc 1.5
e
requirement
s(l/m2/24hr
)
1.5-2
1.5-2
1
1.5
1.5
Multiple of 1
maintenanc
e rate
adminstered
1
1
1
1.5
2.5
Estimated
deficit%
10
5-10
10-15
10
7-10
NA
Time to
replace
deficit(h)
½ 0-12hrs 24-36
½ 13-36hrs
24-36
24-36
½ 0-12
½ 13-36
NA
Total fluids
delivered(lt
/m2/24hrs)
4.35
4.5++
4.0+
5.1
4.35
Saline
bolus(ml/kg
)
4.5++
Mean ± SD
Group 1A
P(1A vs
1B)*
Group 1B
P (1B vs 2)* Group 2
P(1 vs 2)
Age
11.1+/-4.7
NS
10.9+/-4.5
NS
11.4+/-4.6
NS
Wt
39.4+/19.8
NS
37.7+/19.6
NS
44.2+/20.4
NS
Body
surface
area
1.2+/-0.5
NS
1.2+/-0.4
NS
1.4=/-0.5
NS
Males
18
NS
14
NS
16
NS
ICU
admissions
11
NS
8
NS
9
NS
New onset
13
NS
14
NS
12
NS
Glycated
Hb
16.8+/-3.3
NS
16.8+/-3.3
NS
15.9+/-3.1
NS
Ph
7.11+/0.10
NS
7.11+/0.10
NS
7.10+/0.10
NS
Glucose
514+/-167 0.05
630=/-263 NS
538+/-216 NS
Na+
142+/-5
NS
145+/-7.5
NS
145.6+/5.3
NS
K+
4.9+/-1.3
NS
4.9+/-1.2
NS
5+/-0.9
NS
PARTICIPANTS
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Patients with IDDM who received DKA therapy
under a traditional fluid protocol with discharge
diagnosis of DKA from september 1 ,1994 to june
1, 1997 –group 1
Patients treated under the revised fluid protocol
were identified from patients adm-itted from july
1,1997 to march 31,2000-group2
LABORATORY MONITORING
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Each patients
Weight
Vital signs (qh)
Blood glucose (qh)
Venous blood gas (q2hrs if pH is less than7.2,qh hrs
other wise)
Beta-hydroxybutyrate
Electrolytes
Glucose,calcium,phosphorus,magnesium(q4hrs)
Urinary ketones
DATA ANALYSIS
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Differences in profiles of biochemical data of
,&fluid delivered to the patients from the 3 groups
were evaluated using unpaired students test
Differences in the number of IV solution changes for
each patient were evaluated using kruskal-wallis
tests
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Differences between the groups for race,sex,number
of patients admitted to the ICU &the number of
patients presenting with new onset of IDDM were
evaluated using chi-square tests
All data were analyzed with stat view 4.5(abacus
concepts,inc,berkeiey,ca,1996) considered
statistically significant
IMPACT ON MANAGEMENT: 2-BAG
VERSUS 3-BAG PROTOCOLS
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Use of a 3-bag system consisting of an insulin
solution & 2 bags of electrolyte solutions that were
identical
Expect that1contained 10%dextrose ,with the goal
of varying total fluid rate & glucose infusion rate
independently
These subgroups did not differ in total fluid
administration ,time to resolve acidosis,or any
biochemical parameters
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Although the number of fluid changes ordered per
patient was reduced by 23%
This resulted solely from a decreased number of
orders to change the dextrose concentration
IMPACT ON MANAGEMENT :changes
in fluid rate &sodium concentration
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Previous studies had suggested that fluid
administration more than 4l/m2/24hrs (2.7 times
typical maintenance fluid requirements of
1.5l/m2/24hrs) is associated with greater risk of
cerebral edema
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Mean total IV fluid administration over the 1st 24hrs
was lower in patients treated with the new protocol
5.3vs4.1 l/m2,
Time to resolve acidosis also was shorter (16.7 vs
12.6 hrs )
Nonsignificant decrease in mean length of hospital
stay (2.86+/-0.20 vs 2.61 +/-0.11 days)
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Reduced IV fluid costs from $1060 to $776 per
patient
Lab charges from $2752 to $2001 over the 1st hr
of treatment
Average total cost per patient were reduced by
$1036
Impact on biochemical parameters
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No significant changes in total Na+ delivered
Serum Na+ concentrations decreased by similar
amounts (5mmol/l) with both protocols
No significant changes in frequency /degree of
hypokalemia
Group 2 had slightly increases in serum chloride
concentration with treatment
Cerebral edema
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Excessive fluid administration rates are associated
with an increased risk of cerebral edema
Rate of cerebral edema was similar in patients
receiving more fluids than are currently
recommended(group 1 5.3 l/m2/24 hrs)
With group2(average of 4.1l/m2/24hrs)
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Data do not support the idea that reducing these
rates per se reduces the risk of cerebral edema
Moderate reduction in the sodium content of the
fluids ,reduces the number of fluid changes needed
to treat this condition
These changes are associated with decreased time
to resolve acidosis
REFERENCES
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
Kaufman FR . Diabetes in children & adolescents
.areas of controversy .med clin north
am.1998;82:721-738
pinkneyJH,bingleypj,sawtellPA,the barts oxford
study group .presentation &progress of childhood
diabetic mellitus .a prospective population based
study . Diabetologia 1994;37:70-74
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