Background: A substantially reduced fluid replacement regimen was introduced in the New British Society of Paediatric Endocrinology Diabetes (2015) compared to Old(2009) guideline for DKA management. However, data on varying fluid replacement regimens is limited and we explored this by comparing outcomes of the 2 guidelines on the resolution of DKA.
Methods: In a retrospective audit of consecutively admitted patients (age <18 yrs) to 2 UK hospitals with DKA between Jan 2014March 2017, we evaluated the resolution time of DKA defined by recovery of acidosis (pH>7.30), ketosis (blood ketones <1.0 mmol/l) or bicarbonate (>18.0 mmol/l). Biochemical parameters before, the nearest to 4 and 10 hours into treatment and at resolution were collected.
Results: Of 78 patients admitted, data were available for 55[transferred (n=12), data unavailable (n=11)] patients managed by the New (n=23) or Old (n=32) guidelines. The mean age was 10.1 yrs (standard deviation ±4.1), 36 patients (65.5%) were newly-diagnosed and 15 (27.3%) had severe DKA (pH<7.1). Age, DKA severity and proportion of newly-diagnosed patients were similar in both groups. The mean fluid administration rates were substantially lower in the New guideline (29.5±9.6 vs 58.1±16.8 ml/hour, P<0.0001), but frequency of fluid boluses was similar (39% vs 50%, P=0.80). Resolution time of DKA evaluated by pH (New vs Old:13.8±7.5 vs 16.4±9.6 hours, P=0.3] or ketosis (19.3±10.2 vs 18.7±9.8 hours, P=0.82] or bicarbonate levels (17.5±9.1 vs 20.1±12.6 hours, P=0.53) were similar. The levels of glucose, Na, K, Cl and HCO3−, and pH at presentation, 4 and 10 hours of starting treatment and resolution, and hypoglycaemia rates were similar. However, in mild DKA patients managed by the New guideline, the time interval for glucose levels to decline to 14 mmol/l was lower (5.0±3.7 vs 7.4±4.0 hours, P=0.07) and the rate of decline in effective osmolality was faster at 4 hours (8.9±4.4 vs 4.9±6.4 mosm/l per h, P=0.038) and at 10 hrs (2.8±1.0 vs 1.7±1.2 mosm/l per h, P=0.032). No patients developed cerebral oedema.
Conclusions: We found that 50% reduction in the fluid replacement in DKA was not associated with significant changes in resolution time or electrolyte levels. However, decline in effective osmolality and glucose was faster with the reduced fluid replacement. Larger studies are important to evaluate the effects on cerebral oedema.
27 - 29 Sep 2018
European Society for Paediatric Endocrinology