Category: Endocrinology

The Rate of Resuscitation in Pediatric DKA

A few children experience cognitive impairment and cerebral edema following the resuscitation phase of diabetic ketoacidosis. For many years, there has been suspicion the rapid volume replacement with isotonic crystalloids precipitated cerebral edema, leading to protocols requiring conservative rates of fluid administration.

Probably unnecessarily so.

This 2×2 randomized trial tested “fast” versus “slow” fluid resuscitation, as well as isotonic 0.9% saline versus 0.45% saline. “Fast” resuscitation repleted a 10% body weight fluid deficit with half of the fluid in the first 12 hours, while the “slow” resuscitation repleted a 5% fluid deficit at a steady rate over 48 hours. A little more than three hundred patients were included in each arm, with the primary outcome being a decline in mental status as measured by the Glasgow Coma Score. Persistent cognitive impairment, “clinically apparent brain injury”, and other adverse events were tracked as secondary outcomes.

Effectively, there is no discernable difference in outcomes between the four groups. Deterioration of mental status and clinically apparent brain injury were rare – occurring, essentially, around the expected 0.5-1.0% rate regardless of resuscitation speed or fluid selection. Serious adverse events were uncommon and similar across groups, without reliable signals of inferiority to any specific resuscitation strategy.

Whatever you’ve been doing these last few years, at least, hasn’t been “wrong”. Unfortunately, having failed to identify this as a preventable trigger for cerebral injury in DKA, the search for its cause must go on.

“Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis”
https://www.nejm.org/doi/full/10.1056/NEJMoa1716816

The Sweetest Emergency Department Discharge

When the writers of television drama imagine the Emergency Department, they imagine – you know – emergencies.  Life, death, gray areas in between, and the drama of the critically ill.  People with – you know – symptoms.

Now, our Emergency Departments fill up with the asymptomatic – hypertension and hyperglycemia.  Silent killers, to be sure, but on geologic time scales compared to the attention span of the average Emergency Physician.  As we covered last week, asymptomatic hypertension is nearly always an inappropriate Emergency Department referral.  Now, just the same, we see the same strains of futile pedaling in hyperglycemia.

This is a retrospective, single-center evaluation of all patients arriving with a glucose level ≥400 mg/dL and subsequently discharged.  Patient admission and discharge glucose level were measured, any testing and treatment recorded, and each was followed-up specifically for healthcare encounters and hospitalizations within seven days.  All told, they identified 422 patients and 566 ED encounters for chart review.

In their cohort, the median arrival and discharge glucose levels were 491 mg/dL and 334 mg/dL.  Treatment and testing varied wildly, with most receiving some sort of chemistry or urine testing, most receiving some intravenous fluid, and the majority receiving some subcutaneous insulin.  Fabulously, 11 patients were even discharged (most AMA) with glucose beyond the range of the point-of-care machine (600 mg/dL).  Nearly everyone in their cohort for whom they were able to follow-up did well: only 25 (4%) were hospitalized on a re-visit within 7 days, and only two did so for a glucose-metabolism complications, both diabetic ketoacidosis.  The reasonable conclusion of these authors: “attaining a specific glucose-level goal before discharge in patients with moderate to severe hyperglycemia may be less important than traditionally thought.”

This study does not review the downstream resource utilization and outcomes for those admitted on their initial visit.  A comparison with an admitted versus discharged cohort might have given some representation of benefit derived from intensive treatment and re-education, although, the surrogate and patient-oriented complications relating to poor glucose control are infrequent and generally long-term complications.  Furthermore, patients with poor glucose control are not always those for whom an inpatient hospitalization resolves the issues relating to their future poor glucose control.

These patients are still a challenge to manage appropriately.  The role of the Emergency Department is in ruling out treatable pathology or complications of sustained hyperglycemic or insulin-deficient states.  Unlike hypertension, a little more work is usually indicated for these patients.  The ED evaluation is the easy part; finding ways to keep these patients healthy long term is the larger question.

“Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia”
http://www.annemergmed.com/article/S0196-0644(16)30162-7/abstract