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

Yıl 2019, Cilt 41, Sayı 1, 42 - 50, 28.03.2019
https://doi.org/10.7197/223.vi.540887

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. 

Kaynakça

  • Del Pozo P, Aránguiz D, Córdova G Scheu C, Valle P, Cerda J, García H, Hodgson MI, Castillo A. Clinical profile of children with diabetic ketoacidosis in fifteen years of management in a Critical Care Unit. Rev Chil Pediatr. 2018 Aug;89(4):491-498. doi: 10.4067/S0370-41062018005000703.
  • Wolfsdorf JI. The International Society of Pediatric and Adolescent Diabetes guidelines for management of diabetic ketoacidosis: Do the guidelines need to be modified? Pediatr Diabetes. 2014;15(4):277-86.
  • Olivieri L, Chasm R. Diabetic Ketoacidosis in the Pediatric Emergency Department. Emerg Med Clin N Am 2013;755-73.
  • Wolfsdorf J, Craig ME, Daneman D, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes. 2009; 10 Suppl 12: 118-33
  • Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes. 2018 Oct;19 Suppl 27:155-177. doi: 10.1111/pedi.12701.
  • Usher-Smith JA, Thompson MJ, Walter FM. Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review. Diabetologia. 2012; 55(11):2878- 94.
  • Long B, Koyfman A. Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids. J Emerg Med. 2017 Aug;53(2):212-221. doi: 10.1016/j.jemermed. 2017.03.014. Epub 2017 Apr 12.
  • Sherry N, Levitsky L. Managment of Diabetic Ketoacidosis in Children and Adolescents. Pediatr Drugs. 2008; 10(4):209-15.
  • Gülser Esen Besli Başak Nur Akyıldız Hasan Ağın. Çocuk acil tıp ve yoğun bakım derneği. Diabetik ketoasidoz tedavi protokolü 2017. Available at: http://www.cayd.org.tr/gorseller /files/protokoller/CAYDDKA(07012018).pdf.
  • Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WW, Mungai LN, Rosenbloom AL, Sperling MA, Hanas R: ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014;15 Suppl 20:154-179.
  • Duck SC, Wyatt DT: Factors associated with brain herniation in the treatment of diabetic ketoacidosis. J Pediatr 1988;113:10-14.
  • Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N: Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med 2001;344:264-269.
  • Yuen N, Anderson SE, Glaser N, Tancredi DJ, O'Donnell ME: Cerebral blood flow and cerebral edema in rats with diabetic ketoacidosis. Diabetes 2008;57:2588-2594.
  • Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, DiCarlo J, Neely EK, Barnes P, Kuppermann N: Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes 2006;7:75-80.
  • Jefferies CA, Nakhla M, Derraik JG, Gunn AJ, Daneman D, Cutfield WS. Preventing Diabetic Ketoacidosis. Pediatr Clin North Am. 2015; 62(4): 857-71.
  • Edge JA, Hawkins MM, Winter DL, Dunger DB: The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child 2001;85:16-22.
  • Lawrence SE, Cummings EA, Gaboury I, Daneman D: Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr 2005;146:688-692
  • Baalaaji M, Jayashree M, Nallasamy K, Singhi S, Bansal A. Predictors and Outcome of Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian Pediatr. 2018 Apr 15;55(4):311-314. Epub 2018 Feb 9.
  • Zeitler P, Haqq A, Rosenbloom A, Glaser N; Drugs and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment. J Pediatr. 2011;158:9-14,14.e1-2.
  • Weissbach A, Zur N, Kaplan E, Kadmon G, Gendler Y, Nahum E. Acute Kidney Injury in Critically Ill Children Admitted to the PICU for Diabetic Ketoacidosis. A Retrospective Study. Pediatr Crit Care Med. 2019 Jan;20(1):e10-e14. doi: 10.1097/PCC.0000000000001758.
  • Yesilbas O, Cem E, Cimbek EA. Successful treatment of life-threatening severe metabolic acidosis by continuous veno-venous hemodialysis in a child with diabetic ketoacidosis. J Pediatr Endocrinol Metab. 2018 Sep 25;31(9):1043-1045. doi: 10.1515/jpem-2018-0232.
  • Lee SH, Kim BG, Cho AY, Kim SS, Shin HS, et al. A case of diabetic ketoacidosis with refractory metabolic acidosis successfully treated with continuous hemodiafiltration. J Korean Soc Emerg Med 2015;26:480–482.
  • Kawata H, Inui D, Ohto J, Miki T, Suzue A, et al. The use of continuous hemodiafiltration in a patient with diabetic ketoacidosis. J Anesth 2006;20:129–31
  • Jefferies C, Cutfield S, Derraik JG, Bhagvandas J, Albert BB, Hofman PL, et al. 15-year incidence of diabetic ketoacidosis at onset of type 1 diabetes in children from a regional setting (Auckland, New Zealand). Sci Rep. 2015;5:10358.
  • Sola E, Garzon S, Garcia-Torres S, Cubells P, Morillas C, Hernandez-Mijares A: Management of diabetic ketoacidosis in a teaching hospital. Acta Diabetol 2006;43:127-130.
  • Jawaid A, Sohaila A, Mohammad N, Rabbani U: Frequency, clinical characteristics, biochemical findings and outcomes of DKA at the onset of type-1 DM in young children and adolescents living in a developing country - an experience from a pediatric emergency department. J Pediatr Endocrinol Metab 2019;32:115-119.
  • Onyiriuka AN, Ifebi E: Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics. J Diabetes Metab Disord 2013;12:47.
  • Hekkala A, Reunanen A, Koski M, Knip M, Veijola R: Age-related differences in the frequency of ketoacidosis at diagnosis of type 1 diabetes in children and adolescents. Diabetes Care 2010;33:1500-1502.
  • Chumiecki M, Prokopowicz Z, Deja R, Jarosz-Chobot P: [Frequency and clinical manifestation of diabetic ketoacidosis in children with newly diagnosed type 1 diabetes]. Pediatr Endocrinol Diabetes Metab 2013;19:143-147.
  • Razavi Z: Frequency of ketoacidosis in newly diagnosed type 1 diabetic children. Oman Med J 2010;25:114-117.

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

Yıl 2019, Cilt 41, Sayı 1, 42 - 50, 28.03.2019
https://doi.org/10.7197/223.vi.540887

Öz

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. 

Kaynakça

  • Del Pozo P, Aránguiz D, Córdova G Scheu C, Valle P, Cerda J, García H, Hodgson MI, Castillo A. Clinical profile of children with diabetic ketoacidosis in fifteen years of management in a Critical Care Unit. Rev Chil Pediatr. 2018 Aug;89(4):491-498. doi: 10.4067/S0370-41062018005000703.
  • Wolfsdorf JI. The International Society of Pediatric and Adolescent Diabetes guidelines for management of diabetic ketoacidosis: Do the guidelines need to be modified? Pediatr Diabetes. 2014;15(4):277-86.
  • Olivieri L, Chasm R. Diabetic Ketoacidosis in the Pediatric Emergency Department. Emerg Med Clin N Am 2013;755-73.
  • Wolfsdorf J, Craig ME, Daneman D, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes. 2009; 10 Suppl 12: 118-33
  • Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes. 2018 Oct;19 Suppl 27:155-177. doi: 10.1111/pedi.12701.
  • Usher-Smith JA, Thompson MJ, Walter FM. Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review. Diabetologia. 2012; 55(11):2878- 94.
  • Long B, Koyfman A. Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids. J Emerg Med. 2017 Aug;53(2):212-221. doi: 10.1016/j.jemermed. 2017.03.014. Epub 2017 Apr 12.
  • Sherry N, Levitsky L. Managment of Diabetic Ketoacidosis in Children and Adolescents. Pediatr Drugs. 2008; 10(4):209-15.
  • Gülser Esen Besli Başak Nur Akyıldız Hasan Ağın. Çocuk acil tıp ve yoğun bakım derneği. Diabetik ketoasidoz tedavi protokolü 2017. Available at: http://www.cayd.org.tr/gorseller /files/protokoller/CAYDDKA(07012018).pdf.
  • Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WW, Mungai LN, Rosenbloom AL, Sperling MA, Hanas R: ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014;15 Suppl 20:154-179.
  • Duck SC, Wyatt DT: Factors associated with brain herniation in the treatment of diabetic ketoacidosis. J Pediatr 1988;113:10-14.
  • Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N: Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med 2001;344:264-269.
  • Yuen N, Anderson SE, Glaser N, Tancredi DJ, O'Donnell ME: Cerebral blood flow and cerebral edema in rats with diabetic ketoacidosis. Diabetes 2008;57:2588-2594.
  • Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, DiCarlo J, Neely EK, Barnes P, Kuppermann N: Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes 2006;7:75-80.
  • Jefferies CA, Nakhla M, Derraik JG, Gunn AJ, Daneman D, Cutfield WS. Preventing Diabetic Ketoacidosis. Pediatr Clin North Am. 2015; 62(4): 857-71.
  • Edge JA, Hawkins MM, Winter DL, Dunger DB: The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child 2001;85:16-22.
  • Lawrence SE, Cummings EA, Gaboury I, Daneman D: Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr 2005;146:688-692
  • Baalaaji M, Jayashree M, Nallasamy K, Singhi S, Bansal A. Predictors and Outcome of Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian Pediatr. 2018 Apr 15;55(4):311-314. Epub 2018 Feb 9.
  • Zeitler P, Haqq A, Rosenbloom A, Glaser N; Drugs and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment. J Pediatr. 2011;158:9-14,14.e1-2.
  • Weissbach A, Zur N, Kaplan E, Kadmon G, Gendler Y, Nahum E. Acute Kidney Injury in Critically Ill Children Admitted to the PICU for Diabetic Ketoacidosis. A Retrospective Study. Pediatr Crit Care Med. 2019 Jan;20(1):e10-e14. doi: 10.1097/PCC.0000000000001758.
  • Yesilbas O, Cem E, Cimbek EA. Successful treatment of life-threatening severe metabolic acidosis by continuous veno-venous hemodialysis in a child with diabetic ketoacidosis. J Pediatr Endocrinol Metab. 2018 Sep 25;31(9):1043-1045. doi: 10.1515/jpem-2018-0232.
  • Lee SH, Kim BG, Cho AY, Kim SS, Shin HS, et al. A case of diabetic ketoacidosis with refractory metabolic acidosis successfully treated with continuous hemodiafiltration. J Korean Soc Emerg Med 2015;26:480–482.
  • Kawata H, Inui D, Ohto J, Miki T, Suzue A, et al. The use of continuous hemodiafiltration in a patient with diabetic ketoacidosis. J Anesth 2006;20:129–31
  • Jefferies C, Cutfield S, Derraik JG, Bhagvandas J, Albert BB, Hofman PL, et al. 15-year incidence of diabetic ketoacidosis at onset of type 1 diabetes in children from a regional setting (Auckland, New Zealand). Sci Rep. 2015;5:10358.
  • Sola E, Garzon S, Garcia-Torres S, Cubells P, Morillas C, Hernandez-Mijares A: Management of diabetic ketoacidosis in a teaching hospital. Acta Diabetol 2006;43:127-130.
  • Jawaid A, Sohaila A, Mohammad N, Rabbani U: Frequency, clinical characteristics, biochemical findings and outcomes of DKA at the onset of type-1 DM in young children and adolescents living in a developing country - an experience from a pediatric emergency department. J Pediatr Endocrinol Metab 2019;32:115-119.
  • Onyiriuka AN, Ifebi E: Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics. J Diabetes Metab Disord 2013;12:47.
  • Hekkala A, Reunanen A, Koski M, Knip M, Veijola R: Age-related differences in the frequency of ketoacidosis at diagnosis of type 1 diabetes in children and adolescents. Diabetes Care 2010;33:1500-1502.
  • Chumiecki M, Prokopowicz Z, Deja R, Jarosz-Chobot P: [Frequency and clinical manifestation of diabetic ketoacidosis in children with newly diagnosed type 1 diabetes]. Pediatr Endocrinol Diabetes Metab 2013;19:143-147.
  • Razavi Z: Frequency of ketoacidosis in newly diagnosed type 1 diabetic children. Oman Med J 2010;25:114-117.

Ayrıntılar

Birincil Dil İngilizce
Konular Sağlık Bilimleri ve Hizmetleri
Yayınlanma Tarihi March 2019
Bölüm Dahili Tıp Bilimleri Araştırma Yazıları
Yazarlar

Ebru Atike ONGUN (Sorumlu Yazar)
Sivas Cumhuriyet University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Critical Care
0000-0002-1248-8635
Türkiye


Nurullah ÇELİK Bu kişi benim
Sivas Cumhuriyet University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology
0000-0003-1583-6807
Türkiye

Yayımlanma Tarihi 28 Mart 2019
Yayınlandığı Sayı Yıl 2019, Cilt 41, Sayı 1

Kaynak Göster

APA Ongun, E. A. & Çelik, N. (2019). Risk factors associated with resolution of diabetic ketoacidosis in pediatric critical care units . Cumhuriyet Medical Journal , 41 (1) , 42-50 . DOI: 10.7197/223.vi.540887