Sindy Villacres, DO
Pediatric Critical Care Physician, Assistant Professor UCF COM
Nemours Childrens Hospital
Orlando, Florida, United States
Disclosure information not submitted.
Title: Plasmalyte in Pediatric DKA to Reduce Iatrogenic Hyperchloremia, a Quality Improvement Project
Learning Objectives: Pediatric diabetic ketoacidosis (DKA) is a medical emergency requiring admission to the pediatric intensive care unit (PICU) for careful fluid resuscitation, administration of a continuous insulin infusion, and close monitoring of electrolytes and neurologic status. Current guidelines recommend the use of isotonic crystalloid fluid in the management of DKA, however which crystalloid fluid to use is not made clear. The aim of this study is to decrease iatrogenic hyperchloremia in patients admitted with DKA by standardizing the use of plasmalyte for fluid resuscitation in the PICU.
Methods: This was conducted as a single center cohort quality improvement project. We conducted a retrospective chart review of the 12 months prior to intervention to obtain a baseline for points of interest including demographic information, serum chloride levels at admission and peak serum chloride levels, time to resolution of acidosis from presentation, the type of fluids used and both hospital and PICU length of stay. The same data was collected on patients in the 6 months after intervention for comparison. A driver diagram to identify causes of iatrogenic hyperchloremia and multiple PDSA cycles were utilized. The mean pre-intervention peak serum chloride level was compared to the post-intervention peak serum chloride level using an unpaired t-test with equal variances.
Results: A total of 70 patients were analyzed pre-intervention and 41 were analyzed post-intervention. The mean pre-intervention peak serum chloride was 109.7 mEq/L and post was 110.9 mEq/L (p=0.45). The mean time to resolution of acidosis pre-intervention was 16.7 hours and post intervention was 11.2 hours (p=0.07).
Discussion: The use of plasmalyte in place of normal saline during resuscitation for pediatric DKA did not show an appreciable change in peak serum chloride, and while the time to resolution acidosis did decrease it was not statistically significant. With the cost of plasmalyte at slightly more than double the price per unit of normal saline, and the additional time factored in to prepare a bag of plasmalyte, there is no true benefit in using plasmalyte over normal saline in the resuscitation of DKA.