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Abstract
Aims DKA management is standardised by BSPED. Studying current practice helps identify problems in guideline interpretation enabling education and simplification of updates.
Methods The Children’s Acute Transport Service gets complicated DKA referrals for advice/retrieval from North Thames region, recorded on standard admission forms. Retrospective analysis was done 1st January – 31st December 2014. Population characteristics, current DGH practice (following BSPED 2009) and significance of risk factors for cerebral oedema (Fischer exact test) were studied.
Results Total 44 referrals. 37 included as >75% data documented. (Table 1) 12 transferred for cerebral oedema (7), age < 2 years (3), renal failure (2). 2 intubated. No deaths. 18 suspected cerebral oedema- all with low GCS, 6 with headache and 1 bradycardia. 11 improved at DGH : 3 received osmotherapy, 2 decreasing fluids, 4 both, 3 neither. CT Head done in 8 (1 mild cerebral oedema). Practice deviated from guideline in fluid bolus management, delay in start of insulin, hypokalemia management without central access and decreasing fluids for cerebral oedema. (Table 2) 88% received a fluid bolus. 94% with moderate dehydration received 10 ml/kg bolus. 50% received >10 ml/kg for prolonged CRT and tachycardia only. 19% received >10 ml/kg bolus despite estimating <8% dehydration. 11% received >30 ml/kg. 19% delayed start of insulin >2 hrs. Refractory hypokalemia (despite 40 mmol/L delivery) inadequately treated in 3/4. 1 received bicarbonate. 39% decreased fluids for cerebral oedema. Risk factors for cerebral oedema were analysed (Table 3). Admission GCS <=12 has significant association (p = 0.00015).
Population characteristics
Current DGH clinical practice
Significance of risk factors for cerebral edema
Conclusion Population characteristics identified that complicated DKA patients (pH <7.1, age <2years) are at risk of cerebral oedema, electrolyte disturbances, renal failure. Outreach education and guidelines should clarify that fluid boluses should not be guided by delayed CRT (confounded by severe hypocarbia), delays in start of insulin beyond 1 hr should be avoided, emphasise advice on reducing fluid delivery alongwith osmotherapy for cerebral oedema and evaluate options for refractory hypokalemia. Future studies should evaluate evidence justifying risk of CT head in cerebral oedema and whether a 10 ml/kg fluid bolus in the first hour in all severe DKA is a safe standardisation to match clinical practice.