Background Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus. Mortality is predominantly related to the occurrence of cerebral oedema. Management guidelines aim to minimise the risk by producing slow correction of the metabolic abnormalities.
We audited the initial management of children in DKA at referring hospitals prior to referral to a paediatric intensive care retrieval service for advice and/or retrieval.
Methods Data was retrospectively collected on all children in DKA referred to a regional paediatric intensive care retrieval service between 1.4.09 and 31.3.12. Management at referring hospitals was compared to UK guidelines (BSPED 2009).
Results There were 121 episodes of DKA in 115 patients (median age 12.5 (0.7–16.4) years, 45% male). In 72 (60%) cases, DKA was the initial presentation of diabetes. Mean(SD) initial pH was 6.97 (0.11). In 29 (24%) cases, osmotherapy was given because of concerns about cerebral oedema. 34 (28%) cases were retrieved to a paediatric intensive care unit.
115 (95%) cases received fluid boluses as initial resuscitation (mean 22ml/kg). 17 (14%) received more than the recommended maximum of 30ml/kg (40ml/kg n = 11, 50ml/kg n = 4, 60ml/kg n = 2).
Median estimated degree of dehydration was 8% (0–10%). 25 (21%) cases were estimated to be 10% dehydrated (recommended maximum 8%). Deficit was corrected over 48 hours in all cases. Fluid calculations were correct in 39/63 (62%) cases. The commonest reasons for error were failure to subtract initial fluid boluses and inaccurate maintenance calculation. Potassium replacement was given in 76% cases. Bicarbonate (not recommended) was given in 4 (3.3%) cases.
4 patients received an initial insulin bolus (not recommended). The insulin infusion rate was <0.05 units/kg/h in 2 cases, 0.05 units/kg/h in 30 cases and 0.1units/kg/h (recommended) in 80 (66%) cases. Insulin had not yet been commenced in the remaining 9 cases.
Conclusion Despite the existence of clear guidelines, a significant proportion of children with severe DKA received excessive fluid resuscitation, inappropriately/inaccurately calculated ongoing fluid replacement and lower-than-recommended insulin infusion rates. These findings highlight areas that need ongoing education to improve patient care.