Risk factors associated with resolution of diabetic ketoacidosis in pediatric critical care units

Ebru Atike Ongun; Nurullah Çelik

doi:10.7197/223.vi.540887

TR EN

Çocuk yoğun bakımda izlenen diabetik ketoasidoz olgularında ketoasidozdan çıkış sürelerine etki eden faktörler

Öz

Amaç: Diabetik ketoasidoz (DKA), Tip I diabetes mellitusta (DM) mortalite ve morbiditeye neden olan en önemli faktörlerdendir. Bu çalışma ile hastaların geliş laboratuvar ve klinik bulgularından yola çıkarak, ketoasidozdan çıkma sürelerini ön görmeyi ve gelişebilecek komplikasyonlar açısından risk faktörlerini belirlemeyi amaçladık.

Yöntem: Ocak2014-Aralık2018 arasında, Sivas Cumhuriyet Üniversitesi Hastanesi çocuk yoğun bakım servisine (ÇYB), DKA nedeniyle yatan 105 hastanın verileri geriye dönük incelendi. Hastaların demografik verileri, başvuru şikayetleri, muayene bulguları, laboratuvar parametreleri, PRISM skorları, ketoasidozdan çıkış zamanı ile ÇYB ve hastane yatış süreleri kaydedildi. Dehidratasyon derecesine göre ketoasidoz şiddeti (hafif/orta/ağır) derecelendirildi Olgular, yeni ve eski tanılı hastalar olarak iki gruba ayrıldı. SPSS23 ile kategorik ve sayısal veriler değerlendirildi; korelasyon ve çok değişkenli regresyon analizi yapıldı.

Bulgular: Ortalama yaşın 11.31±4.18 yıl, kız/erkek oranının 1/1.4 olduğu çalışmada yeni tanı alan hastaların oranı %51.4 idi. Hastaların %29.5’u hafif, %35.2’si orta, %35.2’si ağır şiddette DKA olduğu görüldü. Bilinç değişikliği %30.5, kusmaull solunum %48.6 gözlenirken, takiplerde bir hastada entübasyon ihtiyacı doğdu. Dört hastada akut böbrek yetmezliği gelişirken bir olguda hemodiyaliz uygulandı. Ketoasidozdan çıkış süresi ortalama 14.30±6.43 saat olup, ÇYB ve hastane yatış süreleri sırasıyla 2.06±1.01 gün ve 7.31±2.11 gündü.

Her iki grup karşılaştırıldığında, yeni tanı alan hastaların yaşlarının daha küçük, bilinç bulanıklığı ve kusmaul solunum sıklığının daha fazla olduğu görüldü (p<0.001, (p=0.006, p=0.002, sırası ile). Öte yandan bu grupta, kilo kaybının en belirgin başvuru şikayeti olduğu görüldü (p<0.001). Önceden tanı alan diabetik hastalarda ise, enfeksiyonların %80.4 orannda ketoasidoza girme nedeni olduğu (p<0.001); BUN ve serum potasyum düzeylerinin daha yükksek olduğu görüldü (sırasıyla p<0.001, p<0.001).

Ketoasidozdan çıkış süresiyle, serum kreatinin, anyon açığı ve hesaplanan ozmolarite değerlerinin pozitif korele olduğu görüldü (sırasıyla r=0.242, r=0.302, r=0.215). Çoklu regrasyon modelinde ise kan gazı pH’da her 0.1 birimlik düşüşün ketoasidozdan çıkma süresini 3.76 saat, yeni tanı hastalık durumunun ise 5.30 saat geciktirdiği saptandı (adjusted ratio:0.743, p>0.001).

Sonuç: DKA lu olgularda başvuru esnasındaki kan pH değeri ve yeni tanı diabetes mellitus varlığı ketoasidozdan çıkışı belirleyen en önemli faktörlerdir.

Anahtar Kelimeler

Tip 1 Diabetes Mellitus,Ketoasidoz,Risk Faktörleri,Çocuk,Çocuk Yoğun Bakım

Risk factors associated with resolution of diabetic ketoacidosis in pediatric critical care units

Abstract

Objective: Diabetic ketoacidosis (DKA) is the main cause of morbidity and mortality in children with type-I Diabetes Mellitus. The goals of therapy are to correct dehydration, resolution of acidosis and fading of ketosis. Such serious complications necessitate closed monitoring of DKA patients with delicate, balanced therapy, probably at an intensive care facility.

Regarding the fact that, each facility shoul determine the clinical profile of their own patient population, we aimed to investigate the risk factors for consequences and determine the timing of DKA resolution by analyzing the demographic and epidemiologic data, clinical outcome and the prognosis of diabetic ketoacidotic children admitted to PICU.

Method: This descriptive, retrospective study was conducted in 105 children admitted to PICU with the complaints of DKA between January 2014 and December 2108. Demograhic data including age, gender, weight, height, body mass index (BMI), initial compliants with clinical findings and level of consciousness were recorded. Children were categorized into two groups depending on the timing of DM diagnosis (new onset of diabetes and established diabetes mellitus). DKA severity was determined by the degree of metabolic acidosis (mild, moderate, severe).

SPSS-23 was used for statictics. Descriptive analyses were expressed as percentages, mean±standart deviation (SD), median with minimum and maximum values. Chi square and Fischer exact test were used for comparison of categorical variables. Student’s t-test, Mann Whitney U test and Wilcoxon rank sum test were assessed for continous variables. Pearson correlation coefficient and logistic regressions were used for correlations and to determine the risk factors. P-value < 0.05 was considered significant.

Results: The patient demographics presented the mean age as 11.31±4.18 years, female/male ratio 1/1.4 and body mass index 18.48±4.48. Children were classified as mild DKA (29.5%), moderate DKA (35.2%) and severe DKA (35.2%) based on the acidosis severity. 48.6% of the patients had Kusmaull respiration; 30.5% had manifested altered consciousness. One patient had tomography-proven brain edema and had required mechanical ventilation due to neurological incapability to sustain airway

Children with new onset of diabetes accounted for 51.4% of the study population. The mean age was 9.70±4.47 years; this group constituted a younger population compared the established DM patients (p<0.001). Altered mental state and kusmaull respiration also occurred at a higher rate and the major complaint seemed ae weight loss within two weeks (p=0.006, p=0.002, p<0.001 respectively).

Children with established diabetes mellitus presented significant biochemical abnormalities in terms of elevated BUN and serum potassium levels (p<0.001, p<0.001); infections occurred as the major triggering factor for DKA at a rate of 80.4% at this group.

We observed a positive correlation with DKA resolution with serum creatinine, calculated osmolality, anion gap (r=0.242, r=0.215, r=0.302) and a negative correlation with blood gas pH and HCO3 (r= -0.704, r= -0.694). In the multivariable regression model including age, gender, body mass index, PRISM-3 score, BUN, serum potassium, phosphate and chloride, only blood gas pH and new onset of diabetes appeared to be the independent risk factors for DKA resolution. 0.1 unit decrement in blood gas pH elongated the resolution by 3.76 hours (p<0.001, adjusted ratio: 0.743). New onset of diabetes mellitus also increased the length of resolution by 5.30 hours (p<0.001).

Conclusions: Inıtial blood gas pH and presence of new onset of diabetes are the major risk factors in resolution of ketoacidosis.

Keywords

Type 1 Diabetes Mellitus,Ketoacidosis,Risk Factors,Children,Pediatric Critical Care

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Details

Primary Language

English

Subjects

Health Care Administration

Journal Section

Research Article

Authors

Ebru Atike Ongun ^*
0000-0002-1248-8635
Türkiye

Nurullah Çelik
0000-0003-1583-6807
Türkiye

Publication Date

March 28, 2019

Submission Date

March 16, 2019

Acceptance Date

March 20, 2019

Published in Issue

Year 1970 Volume: 41 Number: 1

DOI

https://doi.org/10.7197/223.vi.540887

IZ

https://izlik.org/JA39AG57YK

Cite

RIS / Bibtex

AMA

1.Ongun EA, Çelik N. Risk factors associated with resolution of diabetic ketoacidosis in pediatric critical care units. CMJ. 2019;41(1):42-50. doi:10.7197/223.vi.540887

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