Endocrine Abstracts

Introduction: Diabetic Ketoacidosis (DKA) is a life-threatening complication of Type-1 diabetes mellitus (T1DM) in children and young people (CYP). An Integrated Care Pathway (ICP) for management of DKA is established in Wales with the 3rd edition published in March 2016. This is based on the 2015 British Society for Paediatric Endocrinology and Diabetes (BSPED) guidelines.

Aims: To audit the management of DKA in a teaching hospital following the introduction of the third edition of the ICP, with a focus on fluid therapy.

Methodology: Retrospective case note review of all children admitted in DKA to the Children’s Hospital between June 2016 and June 2018.

Results: A total of 24 episodes of DKA were recorded in 23 patients (13 female). The median age was 11 years (range 1–16 years). 9 of the DKA episodes were in newly diagnosed CYP. Omission of insulin was the most common precipitant in those with established TIDM. In all episodes, the diagnosis of DKA was made using blood glucose >11 mmol/l, blood ketones >3 mmol/l and pH <7.3. Eleven patients presented with a pH of <7.1, of which 10 received a 10 ml/kg fluid bolus of 0.9% saline, 6 of whom required a further fluid bolus following clinical assessment. Of the 13 patients with a pH ≥7.1, 6 required 10 ml/kg of 0.9% saline fluid boluses, 2 of whom required the bolus after 2-3 hours of initiation of DKA management, and 1 required a further 10 ml/kg bolus. The maintenance fluid infusion rate was increased in 1 case. Hypoglycaemia was documented in 10 of the 24 episodes whilst on the pathway, despite having dextrose in their fluids.

Conclusion: A significant proportion of CYP being treated for DKA needed a change in fluid therapy when treated in accordance with the current guideline. This change was made based on ongoing clinical assessments. No adverse outcomes were identified. There was an increased incidence of hypoglycaemia despite a reduction in the rate of insulin in the current guideline. This audit suggests that fluid therapy in DKA requires further evaluation and comparison with other centres using the ICP and BSPED guidance.