Management of diabetic ketoacidosis varies across pediatric specialties

Researchers have identified significant variations in diabetic ketoacidosis management among pediatricians and subspecialists. Most subspecialists, general pediatricians and trainees perceived a need for written guidelines on the management of diabetic ketoacidosis, as there is no standardized procedure in the United States, according to research presented at the 2010 Pediatric Academic Societies Annual Meeting.

A study was conducted to assess variations in diabetic ketoacidosis management among general pediatricians, subspecialists, pediatric residents and fellows. An online survey was administered to gauge knowledge and management of diabetic ketoacidosis.

Of the 577 respondents, 44% were subspecialists, 31% were general pediatricians and 25% were pediatric residents and fellows.

Eighty-one percent of pediatric residents and fellows perceived a need for written guidelines, followed by 73% of general pediatricians and 62% of subspecialists.

Bicarbonate was considered for management of diabetic ketoacidosis by 60% of general pediatricians, 58% of pediatric residents and fellows, and 50% of subspecialists (P<.001).

Initial fluid bolus of 10 mL/kg vs. 20 mg/dL for more than one hour was considered by only 31% of subspecialists (including 53% endocrinologists), 24% of general pediatricians and 16% of pediatric residents and fellows (P=.003).

Half of the general pediatricians chose 5% dextrose and 28% chose the two-bag titrating technique when compared with other dextrose concentrations (P<.001); 47% of pediatric ICU subspecialists preferred using the two-bag technique.

Further, a combination of potassium chloride and potassium phosphate was the preferred potassium treatment for 48% of general pediatricians when compared with other forms of potassium. Potassium chloride alone was preferred by 18% of general pediatricians (P<.001).

The data were presented at a Lawson Wilkins Pediatric Endocrine Society session at the 2010 Pediatric Academic Societies Annual Meeting.

The optimal management strategy for diabetic ketoacidosis has been a topic of controversy for decades. Disagreement has mainly centered on how to best prevent the occurrence of cerebral edema, the most frequent serious complication of diabetic ketoacidosis in children. At present, however, the pathophysiology of diabetic ketoacidosis-related cerebral edema is incompletely understood. Furthermore, because the occurrence of clinically apparent cerebral edema is infrequent (approximately 1% of diabetic ketoacidosis episodes), this condition is difficult to study, requiring a very large study sample to collect meaningful results. Therefore, there is very little evidence to guide clinical care and, as a result, management practices vary widely. The information collected in this study underscores the need for large clinical trials studying pediatric diabetic ketoacidosis management practices such that greater uniformity of clinical practice in the United States and elsewhere can be achieved.

– Nicole S. Glaser, MD

Associate Professor of Pediatric Endocrinology,
University of California Davis School of Medicine

For more information:

Chandratre SR. #2856.437. Presented at: 2010 Pediatric Academic Societies Annual Meeting; May 1-4, 2010; Vancouver, British Columbia.