VARIABILITY IN EMERGENT MANAGEMENT OF DIABETIC KETOACIDOSIS IN PEDIATRICS: A RETROSPECTIVE CHART REVIEW
Bibliographic record
Abstract
Abstract BACKGROUND Variability in the management of paediatric diabetic ketoacidosis (DKA) has been well described in the literature. Although there are many paediatric DKA management guidelines available at tertiary care centres, there seems to be a lack of familiarity with these in some community hospitals, leading to management inconsistent with evidence-based clinical practice. OBJECTIVES Our objectives were to review the management of paediatric patients who present in DKA, identify those that received initial emergent treatment not consistent with current guidelines, and track associated complications. DESIGN/METHODS Forty-seven charts of paediatric patients admitted to our institution (including patients transferred from peripheral hospitals) from January, 2012 to July, 2017 were identified by ICD-10 codes containing “ketoacidosis”. Primary outcome measures for inadequate management included major risk factors for cerebral edema - IV insulin boluses, IV bicarbonate boluses, hypo-osmolar IV fluid administration and non-NPO status - as well as inappropriate IV fluid boluses>10mL/kg, insulin infusion initiated within the first hour after IV fluids were initiated, and inadequate potassium replacement. RESULTS At least one area of inadequate management occurred at a rate of 74.5% with no significant difference between community hospitals and our tertiary centre. The most common parameter was inadequate replacement of potassium (44.7%), followed by receiving an IV fluid bolus>10mL/kg (40.4%). Twenty-three percent of patients received inadequate management that included a treatment-related major risk factor for cerebral edema. The most common complication was hypoglycemia (BG<4.0mM; 14.9%) and there were no cases of cerebral edema or patients that received a CT head. Though the mean time to insulin infusion initiation was 4.0 hours at outside centres and 2.8 hours at our tertiary centre, the difference was not statistically significant (p=0.26). However, there was a statistically significant difference in time to correction of acidosis, with correction of DKA happening more quickly at our tertiary centre (9.5h compared to 12.7h at outside centres; p=0.03). CONCLUSION Optimal paediatric DKA management continues to be a challenge despite the presence of multiple, evidence-based guidelines. Gradual resuscitation with appropriate fluids appears to be the most common area in which variability exists in community and tertiary care centres.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.008 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.004 | 0.005 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".