Jeff Moss, BCCCP, PharmD
Clinical Specialist Pharmacist
Lucile Salter Packard Childrens Hospital Stanford
Palo Alto
Disclosure information not submitted.
Nozomi Giese-Kim, PharmD
Clinical Pharmacist
Department of Pharmacy, Lucile Packard Children’s Hospital Stanford, United States
Disclosure information not submitted.
Sheila Margossian, DNP
Nurse Practitioner
Department of Pediatric Critical Care Medicine, Lucile Packard Children’s Hospital Stanford, United States
Disclosure information not submitted.
Elizabeth Dorwart, DO, MS
Pediatric Critical Care Fellow
Division of Critical Care, Department of Pediatrics, Stanford University
Palo Alto, California, United States
Disclosure information not submitted.
Saraswati Kache, MD
Clinical Professor Medical Director - Pediatric Critical Care Transport Services
Division of Critical Care, Department of Pediatrics, Stanford University, United States
Disclosure information not submitted.
Sejal Shah, MD
Clinical Assistant Professor
4Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, United States
Disclosure information not submitted.
Title: DKA Pathway to Keep Errors at Bay: Standardizing DKA Management in a PICU
Introduction: Evidence-based management of pediatric diabetic ketoacidosis (DKA) is essential for preventing morbidity and mortality in patients with type-1 diabetes mellitus. A standardized approach may be associated with improved outcomes such as intensive care unit (ICU) length of stay or hypoglycemic episodes. While guidelines exist to support general treatment approaches, essential specific interventions are not established. The aim of this quality improvement study was to evaluate the impact of a DKA clinical pathway and order set.
Methods: Interventions including development of a clinical pathway and order set revisions were completed in 2019. We identified patients who received an insulin infusion through the DKA order set from 1/1/18-12/31/18 compared to those who received this therapy using the order set from 4/1/20-3/30/21. Patients were evaluated for practice-based factors such as starting insulin infusion rate and ordering of potentially harmful custom intravenous fluids, as well as outcomes such as duration of insulin infusion, incidence of hypoglycemic episodes, treatment of cerebral edema, and ICU and hospital length of stay.
Results: We identified 53 patients in the pre-intervention arm and 64 in the post-intervention group. Patients were well-balanced in age, gender and known history of type-1 diabetes mellitus. More patients in the post-intervention group were initiated at our institution’s recommended starting rates based on age (80 vs 53%, p=0.002). Fewer patients required titration of the insulin rate (25% vs 40%, p=0.009) in the post-intervention group. Two patients in each group had orders placed for potentially harmful custom IV fluids. There was a trend towards reduced time from insulin infusion until anion gap improvement ( < 15) (p=0.056), but no difference in duration of insulin infusion (p >0.05). There were no differences in incidence of moderate or severe hypoglycemia or hypo- or hyperkalemia during the infusion. Two patients in each arm received hyperosmolar therapy with mannitol or 3% sodium chloride (p >0.05). The ICU and hospital lengths of stay were not significantly different between the groups.
Conclusion: This targeted quality improvement highlights the need for additional research evaluating the optimal management of pediatric DKA.