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Preventing diabetic ketoacidosis requires community-based advocacy
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In December 2008, we were called to emergently evaluate a 12-month-old with new-onset type 1 diabetes. Upon arrival to our emergency department, he was lethargic, dehydrated and demonstrating classic Kussmaul breathing. His laboratory evaluation revealed arterial pH 6.9, serum bicarbonate 2 mmol/L and glucose 620 mg/dL.
Two days before admission to our pediatric intensive care unit, this infant was seen at a local emergency department with vomiting, dehydration and fever. The patient was discharged with the diagnosis of pharyngitis after being rehydrated and given an antiemetic and a dose of antibiotics. History obtained during his PICU admission showed that this patient had lost several pounds over the last month, had increased urine output with over five wet diapers a night the previous two weeks, and had been drinking bottle after bottle over the last week. Fortunately, our patient recovered from his DKA without incident and was transitioned to subcutaneous insulin within 36 hours of admission. Sadly, based on my three short years of experience admitting new-onset type 1 diabetes patients, the misdiagnosis of new-onset type 1 diabetes remains a common event.
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This story exemplifies another missed opportunity to prevent hospitalization for DKA in a patient already demonstrating signs and symptoms of diabetes during a previous doctor visit.
World Diabetes Day is now held annually on November 14 and was introduced in 1991 by the International Diabetes Federation and the World Health Organization in response to the rapidly increasing number of people diagnosed with diabetes. Their campaign declares “no child should die of diabetes” and states that DKA is the major cause of death in children with type 1 diabetes. In fact, the mortality of patients diagnosed with DKA is approximately one in 100, and most often this is a result of cerebral edema. Although the direct causes of cerebral edema remain unclear, the best way to prevent this complication is undeniably to prevent the episode of DKA itself.
In 1999, Vanelli et al published a paper detailing how a prevention program that educated teachers, parents, students, and general pediatricians about the early and late signs of type 1 diabetes impressively reduced the incidence of DKA in new-onset type 1 diabetes. In addition to education, pediatricians were given equipment for measurement of capillary blood glucose and glycosuria.
Nearly 10 years later, a considerable number of pediatricians do not have the tools to perform these simple and perhaps life-saving tests in their office.
Most of us participating in the care of patients with diabetes are fortunate to have access to spare glucometers, lancets, glucose strips and urine glucose and ketone strips. When talking to a referring physician or nurse, offering them these supplies and appropriate education on their use may be the key to early diagnosis or prevention of DKA. As fellows training in endocrinology or pediatric endocrinology, we often act as the first line of defense for referring physicians and should take advantage of these opportunities as a diabetes advocate to offer these services.
Become advocates
Many training programs now offer or require an advocacy month as one of the rotations in their curriculum during internal medicine, family medicine or pediatric residency. As endocrinologists and/or diabetologists we should encourage resident physicians to participate and offer education to referring physicians, nurses and schools as part of their advocacy curriculum or as they rotate through the endocrine service. The IDF and International Society for Pediatric and Adolescent Diabetes offers free posters for download that can be used for local advocacy campaigns detailing the “warning signs” of diabetes (visit www.worlddiabetesday.org).
Finally, since treating type 1 diabetes is often a multidisciplinary approach, consider organizing or participating in joint conferences and journal clubs with involved caregivers to discuss current literature. An appropriate example of this would be an update on current strategies for the initial care of patients with DKA in the emergency setting. We still frequently see patients that receive sodium bicarbonate acutely for treatment of acidosis, IV insulin pushes, and delayed use of mannitol despite presence of neurological symptoms in order to obtain computed axial tomography of the head.
As advocates for children with diabetes, it is our responsibility to make sure that our fellow physicians have the necessary information to make informed decisions, provide appropriate care and prevent adverse outcomes.
Henry J. Rohrs III, MD, is a Pediatric Endocrinology Fellow in the Department of Pediatrics at the University of Florida and is a member of the Endocrine Today Fellows Advisory Board.
For more information:
- Vanelli M. Diabetes Care. 1999;22:7-9.
- Wolfsdorf J. Ped Diabetes. 2007;8:28-42.
- World Diabetes Day. 2007-2008. International Diabetes Federation. Accessed January 3, 2009. www.worlddiabetesday.org.