Diabetic ketoacidosis Predictors of outcome in a pediatric intensive care unit of a developing country*

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Objectives:To study the outcome and predictors of mortality in children with diabetic ketoacidosis.Design:Retrospective case series.Setting:Pediatric intensive care unit of an urban multiple-specialty teaching and referral hospital in north India.Patients:Sixty-eight patients with diabetic ketoacidosis treated between 1993 and 2000.Interventions:Data were retrieved from case records with respect to patients’ age; clinical features; osmolality at admission; blood glucose, serum potassium, and arterial pH at admission, 6 hrs, and 24 hrs; complications during the course of hospital stay; treatment; and outcome in terms of survival or death. Survivors and nonsurvivors were compared to determine the predictors of mortality.Measurements and Main Results:The mean (sd) age of the study population was 6.9 (3.5) yrs (range, 0.5–12 yrs). Impaired consciousness (n = 45; 66%), rapid breathing (n = 41; 60%), and vomiting (n = 35; 51.4%) were common presenting symptoms. Thirty-two (50%) patients had clinically evident dehydration. Precipitating events identified were new-onset diabetes with sepsis (37%), new-onset diabetes alone (31%), insulin omission (15%), and infection with insulin omission (7%). The mean (sd) blood glucose, osmolality, and pH at admission were 473 (sd 184) mg/dL, 305 (sd 24) mOsm/L, and 7.08 (sd 0.1), respectively. Complications noted during treatment were hypokalemia (n = 28; 41%), hypoglycemia (n = 10; 15%), cerebral edema (n = 9; 13.2%), and pulmonary edema (n = 2; 3%). Nine (13.2%) patient died, with the causes of death being septic shock (n = 4), cerebral edema (n = 2), cerebral edema with pulmonary edema (n = 2), and hypokalemia with ventricular tachycardia (n = 1). Those who died were older, had higher osmolality and severe acidosis at admission, and had persistent hyperglycemia and acidosis at 6–12 hrs. On multiple logistic regression analysis, osmolality at admission was the most significant predictor of death.Conclusions:Two thirds of children with diabetic ketoacidosis in our series had new-onset diabetes, and 13.2% died. Serum osmolality at admission was the most important predictor of death.

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