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Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols

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Abstract

The best protocol for severe inaugural diabetic ketoacidosis (DKA) in children remains unclear. We compared two protocols by assessing effects during the first 24 h on osmolality, serum sodium, and glucose variations, which are associated with the risk of cerebral oedema, the most dreaded complication of DKA. We also recorded complications. We retrospectively included children aged 28 days to 18 years and admitted for severe DKA to either of two paediatric intensive care units (PICUs) in Paris (France). The two protocols differed regarding hydration volume, glucose intake, and sodium intake. From 17 June 2010 to 17 June 2015, 93 patients were included, 29 at one PICU, and 64 at the other. We compared severe glycaemic drops (> 5.5 mmol/L/h), mean glycaemia variations, serum sodium, serum osmolality, and the occurrence of cerebral oedema (CE) during the first 24 h after PICU admission. Severe glycaemic drops occurred in 70% of patients, with no between-group difference. Blood glucose, serum sodium, and serum osmolality variations were comparable. Seven (7.5%) patients were treated for suspected CE, (4 [10.3%)] and 3 [6.3%]) in each PICU; none had major residual impairments.

Conclusion: The two paediatric DKA-management protocols differing in terms of fluid-volume, glucose, and sodium intakes had comparable effects on clinical and laboratory-test changes within 24 h. Major drops in glycaemia and osmolality were common with both protocols. No patients had residual neurological impairments.

What is Known:

• Cerebral oedema is the most severe complication of diabteic ketoacidosis in children.The risk of cerebral oedema is dependant on both patient related and treatment-related factors.

• The optimal protocol for managing severe inaugural diabetic ketoacidosis in children remains unclear, and few studies have targeted this specific population.

What is New:

• Two management protocols that complied with ISPAD guidelines but differed regarding the amounts of fluids, glucose, and sodium administered produced similar outcomes in children with severe inaugural diabetic ketoacidosis.

• Cerebral oedema was rare with both protocols and caused no lasting impairments.

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Data availability

The study data will be made available to researchers upon reasonable request.

Code availability

Not applicable.

Abbreviations

CBG:

Capillary blood glucose

CE:

Cerebral oedema

DKA:

Diabetes ketoacidosis

ECG:

Electrocardiogram

ISPAD:

International Society for Paediatric and Adolescent Diabetes

PICU:

Paediatric intensive care unit

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Author information

Authors and Affiliations

  1. Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

    Laure Maurice, Stéphane Dauger & Fleur Le Bourgeois

  2. Paediatric Mobile Emergency Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

    Sébastien Julliand

  3. Department of Paediatric Endocrinology, Gynaecology, and Diabetology, IMAGINE Affiliate, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

    Michel Polak

  4. Department of Paediatric Endocrinology and Diabetology, Robert Debré Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

    Elise Bismuth & Caroline Storey

  5. Paediatric Intensive Care Unit, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

    Sylvain Renolleau

  6. Université de Paris, Paris, France

    Michel Polak, Sylvain Renolleau & Stéphane Dauger

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  1. Laure Maurice
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Contributions

Laure Maurice collected the data, drafted the manuscript, and revised the manuscript for important intellectual content. Stéphane Dauger and Fleur Le Bourgeois supervised the study and revised the manuscript for important intellectual content. Sebastien Julliand performed the statistical analysis. Michel Polak, Sylvain Renolleau, Elise Bismuth, and Caroline Storey revised the manuscript for important intellectual content.

Corresponding author

Correspondence to Laure Maurice.

Ethics declarations

Ethics approval

The study was approved by the Necker Enfants-Malades ethics committee (#2016-FLB-6).

Consent to inclusion in the study

According to French law on retrospective studies of anonymised data, consent of the patients and parents was not required. However, patients and parents could decline participation.

Conflict of interests

The authors declare no competing interests.

Additional information

Communicated by Daniele De Luca

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Maurice, L., Julliand, S., Polak, M. et al. Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols. Eur J Pediatr 181, 1497–1506 (2022). https://doi.org/10.1007/s00431-021-04332-4

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