Authors: Alexa Ruzicka, Magen Check, Austin Weiss, Tamara Downing, Ashlee Baucom
Background:
Diabetic ketoacidosis (DKA) is a serious complication of insulin deficiency and a leading cause of hospitalization and mortality among children with type 1 diabetes mellitus (T1DM). Intravenous fluid resuscitation is a critical component of DKA therapy. However, fluid therapy in children carries unique risks, most notably cerebral edema. To mitigate these risks, current pediatric guidelines recommend gradual correction of hyperglycemia and acidosis using continuous insulin infusion and staged fluid replacement. Many institutions utilize a two-bag method, which allows for rapid titration of dextrose concentration while maintaining a continuous insulin infusion and consistent electrolyte delivery. The composition of the standard DKA bags used in the two-bag protocol was changed at the study institution in June 2024. The purpose of this study was to compare clinical outcomes before and after the implementation of the revised two-bag fluid composition for pediatric DKA.
Methods:
This study is an institutional review board approved, single center, retrospective cohort study. Pediatric patients (≤ 17 years of age) with a diagnosis of T1DM admitted to the PICU for management of DKA between June 1, 2023, and July 1, 2025, were eligible for inclusion. DKA was defined according to institutional and International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria. Patients were excluded if custom IV fluid bags were utilized during DKA management. The primary endpoint was the time (in hours) from initiation of IV insulin infusion to transition to subcutaneous insulin therapy, which was a surrogate marker for DKA resolution. Secondary outcomes included time to DKA resolution, defined by biochemical markers including serum bicarbonate, anion gap closure, venous pH and beta-hydroxybutyrate. Additional secondary outcomes included PICU and total hospital length of stay, and incidence of cerebral edema, hypoglycemia and hyperchloremia. Mann-Whitney U tests were used to evaluate baseline characteristics, time to DKA resolution, and length of stay. Chi-squared tests were utilized to evaluate the incidence of treatment-related complications.
Results:
109 pediatric patients met inclusion criteria. There were 44 patients and 65 patients in the previous and current bag composition groups, respectively. Baseline characteristics were similar between groups. The median time to transition to subcutaneous insulin was shorter in the current bag composition group compared to the previous bag composition group (11.98 hours vs 13.75 hours, p = 0.174). There was no statistically significant difference in the biochemical endpoints of DKA resolution between groups.
Rates of treatment-related complications were comparable between groups. The incidence of severe hypoglycemia (< 70 mg/dL) was low in both cohorts (2% vs 3%, p = 0.523), with moderate hypoglycemia occurring at a higher rate (< 100 mg/dL) (23% vs 37%, p = 0.117). Hyperchloremia occurred at a similar rate in both groups (82% vs 83%, p = 0.865). There were no statistically significant differences in cerebral edema (2% vs 6%, p = 0.342) or new-onset T1DM (36% vs 28%, p = 0.338). There were no significant differences observed in PICU length of stay (26.16 vs 27.32 hours, p = 0.91). However, the total hospital length of stay was longer in the current bag composition group (33.9 vs 35.6 hours, p = 0.03).
Conclusion:
The modification of the two-bag IV fluid composition for pediatric DKA did not result in significant differences in time to DKA resolution, complication rates, or PICU length of stay. Hospital length of stay was longer in the current bag composition group.
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