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Adherence to the 2015 and 2020 British Society of Paediatric Endocrinology and Diabetes guidelines and outcomes in critically ill children with diabetic ketoacidosis: a retrospective cohort study
  1. Victoria Mary Edwards1,2,
  2. Claire Procter3,
  3. Andrew J Jones1,
  4. Elise Randle1,
  5. Padmanabhan Ramnarayan1,4
  1. 1 Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
  2. 2 Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  3. 3 Department of Paediatrics, Red Cross Children's Hospital, Cape Town, South Africa
  4. 4 Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery, Imperial College London Faculty of Medicine, London, UK
  1. Correspondence to Dr Padmanabhan Ramnarayan, Reader in Paediatric Critical Care, Imperial College London, London, UK; p.ramnarayan{at}imperial.ac.uk

Abstract

Objectives To compare clinical management and key outcomes of critically ill children with diabetic ketoacidosis (DKA) in two cohorts (2015 cohort: managed according to the 2015 British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines; 2020 cohort: managed according to the 2020 BSPED guidelines).

Design Retrospective cohort study using prospectively collected data.

Setting A critical care advice and transport service based in London, and referring hospitals within the critical care network.

Patients All children 0–17 years referred for advice and/or critical care transport with a clinical diagnosis of DKA over a 30-month period (from September 2018 to March 2021).

Interventions None.

Main outcome measures Admission to intensive care unit (ICU), clinically diagnosed cerebral oedema and death.

Results There were significant differences in fluid and insulin administration practices between the 2015 and 2020 cohorts (fluid bolus >20 mL/kg: 3% vs 30%, p<0.001; median total fluid given in the first 24 hours: 84 mL/kg vs 117 mL/kg, p<0.01; starting insulin infusion rate 0.1 U/kg/hour: 54% vs 31%, p<0.01). However, these differences were consistent with guideline recommendations (initial fluid infusion rate within 5% of guideline-recommended rate: 80% in the 2015 group vs 84% in the 2020 group). There were no significant differences in outcomes (ICU admission: 26% vs 35%, p=0.2; cerebral oedema: 21% vs 23%, p=0.8).

Conclusions Our study findings indicate that changes to fluid and insulin administration occurred after the 2020 BSPED guideline publication, with strong adherence to the guideline, but these changes were not associated with changes in key outcomes.

  • paediatrics
  • endocrinology
  • intensive care units, paediatric
  • intensive care units

Data availability statement

Data are available upon reasonable request. Raw data were generated from the the CATS database (Swiftcare, Kinseed, UK). Derived data supporting the findings of this study are available from the corresponding author on request.

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Data availability statement

Data are available upon reasonable request. Raw data were generated from the the CATS database (Swiftcare, Kinseed, UK). Derived data supporting the findings of this study are available from the corresponding author on request.

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Footnotes

  • Contributors PR conceived the idea and presented it. PR, VME and CP designed the study. VME and CP collected the data. Following data collection, VME and PR performed the analysis of the data. All authors, VME, PR, CP, AJJ and ER, reviewed and contributed to interpretation of the data. VME wrote the initial draft of the manuscript and this was reviewed and revised by PR, CP, AJJ and ER. The manuscript was reviewed by all authors and all authors approved the final version of the manuscript to be published. PR is the guarantor of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.