ESPE Abstracts (2015) 84 P-3-698

Adherence to Diabetic Ketoacidosis Management Protocol: a Paediatric Centre Experience

Daphné Cloutier, Joanie Barbe, Isabelle Bouchard, Julie Gagné & Macha Bourdages


Centre Mère-Enfant-Soleil du CHU de Québec, Québec, Québec, Canada


Background: Paediatric diabetic ketoacidosis (DKA) management should be regulated by specific protocols. Following the Canadian Diabetes Association recommendations, our paediatric tertiary care hospital was provided with such a protocol in 2009.

Objective and hypotheses: Assess the proportion of DKA episodes that are marked by non-adherence to our DKA management protocol (DKAp). We suspected a moderate non-adherence rate.

Method: We conducted a retrospective study on all patients admitted with DKA between March 2009 and September 2013. Deviations to DKAp were classified as major or minor according to their potential impact on patient outcome. Non-adherence to acute management DKAp was defined as the occurrence of greater than or equal to one major or greater than or equal to two minor deviations.

Results: Seventy-nine patients were included (mean age: 9.7±4.9 years; 53.2% females). Most cases were new-onset diabetes (60/79, 75.9%). Within known diabetic patients, the DKA precipitating factor was poor treatment compliance in 10/19 (52.6%) and insulin pump dysfunction in 4/19 (21%). Mild DKA (pH: 7.21–7.30) occurred in 24 (30.4%) patients, moderate DKA (pH: 7.11–7.20) in 30 (38.0%) and severe DKA (pH ≤7.10) in 25 (31.6%). Continuous insulin drip was used in 73/79 (92.4%) cases. We observed greater than or equal to one major deviation to DKAp in 37/73 (50.7%) cases, mostly failure to monitor hourly neurological status (32/69, 46.4%, four missing values) and inappropriate administration of 0.9% NaCl i.v. bolus in well-hydrated patients (5/73, 7%). Minor deviations (≥2) occurred in 66/73 (90.4%) patients; mostly failure to monitor urine ketone levels every 4 h (66/73, 90.4%) and blood gas and serum electrolytes every 2 h (33/73, 45.2%). Overall, non-adherence to DKAp occurred in 69 (94.5%) cases. The following complications were observed: 7/73 (9.6%) hypoglycemia, 55/73 (75.3%) hyperchloremic acidemia, and 1 (1.4%) CT-scan suspected cerebral edema. No deaths occurred.

Conclusion: Non-adherence to DKAp was observed in the majority of cases without unusual complication rate. The establishment of a protocol does not guarantee its adherence and surveillance of its application is needed.

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