Evaluation of the Effect of Fluid and Electrolyte Therapy on Electrolytes and Acidosis Resolution Time in Diabetic Ketoacidosis

Abstract

Objective: Fluid replacement and insulin infusion are the cornerstones of treatment of diabetic ketoacidosis, but the optimal volume, rate of infusion, and electrolyte content of fluid replacement have been controversial. The aim of this study was to investigate the effects of treatment on pH, bicarbonate (HCO3), anion gap, chloride, and potassium levels as well as time to resolution of acidosis in children with diabetic ketoacidosis. Material and Methods: Ninety-six episodes with diabetic ketoacidosis between January 2015-December 2017 were evaluated. Results: The mean resolution time of acidosis was 13.4±7.1 hours. Anion gap was returned to normal in 68 (70.8%) episodes at the 4th hour of treatment with a mean of 11±4.2 mmol/L. Episodes with potassium phosphate (KPO4) replacement resulted in a faster increase in pH and a significantly shorter resolution time of acidosis (p<0.001). Acidosis persisted at the 16th hour of treatment in episodes with lower pH, lower serum bicarbonate (HCO3) and higher white blood cell (WBC) counts on admission (p<0.001, p=0.003 p=0.033, respectively). Hyperchloremia (Cl/Na ratio > 0.79) was observed in 97% of cases after 8 hours of treatment. Conclusion: Although the value of the anion gap in predicting acidosis is controversial, severe DKA episodes and high white blood cell count at admission; potassium replacement with high amounts of chloride and KCl containing fluids given during treatment have been associated with a longer recovery time of acidosis.

Keywords

• acidosis
• diabetic ketoacidosis
• hypopotasemia
• pediatric
• Type 1 Diabetes

Diyabetik Ketoasidoz Hastalarında Sıvı ve Elektrolit Tedavisinin Elektrolit Düzeyleri ve Asidoz Düzelme Süresine Etkisi

Abstract

Amaç: Sıvı replasmanı ve insülin infüzyonu Diyabetik Ketoasidoz DKA tedavisinin temel taşlarıdır, ancak sıvı replasmanının optimal hacmi, infüzyon hızı ve elektrolit içeriği hala tartışmalı olan bir konudur. Bu çalışmanın amacı, diyabetik ketoasidozlu çocuklarda tedavinin pH, bikarbonat (HCO3), anyon açığı, klorür ve potasyum düzeyleri üzerindeki etkilerinin yanı sıra asidozun düzelme süresini araştırmaktı. Gereç ve Yöntemler: Ocak 2015-Aralık 2017 tarihleri arasında diyabetik ketoasidoz tanısı ile takip edilen 93 hasta (toplam 96 DKA atağı) retrospektif olarak değerlendirildi. Bulgular: Asidozun ortalama düzelme süresi 13.4±7.1 saatti. Anyon açığı 68 (%70.8) atakta tedavinin 4. saatinde ortalama 11±4.2 mmol/L ile normale döndü. Potasyum fosfat (KPO4) replasmanı yapılan hastalarda pH artışı daha hızlı ve asidoz düzelme süresi daha kısa olarak saptandı (p<0.001). Başvuruda daha düşük pH, daha düşük serum bikarbonat (HCO3) ve daha yüksek beyaz küre sayısı olan ataklarda tedavinin 16. saatinde asidozun devam ettiği görüldü (sırasıyla p<0.001, p=0.003 p=0.033). Hiperkloremi (Cl/Na oranı > 0.79) tedavinin 8. saatinde atakların %97’sinde tespit edildi. Sonuç: Asidozu yansıtmada anyon açığının değeri tartışmalı olarak bulunsa da, DKA ataklarının ağır derecede olması ve hastaneye yatışta beyaz kürenin yüksek olması; tedavi sırasında verilen yüksek miktarda klorür ve KCl içeren sıvı ile potasyum replasmanı asidozun daha uzun sürede düzelmesi ile ilişkilendirilmiştir.

Keywords

• Asidoz
• diyabetik ketoasidoz
• hipopotasemi
• pediatri
• tip 1 diyabet

References

1. Sezer A, Paketçi A, Gören Y, Çatlı G, Ahmet A, Tuhan H, et al. Evaluation of Demographic, Clinical and Laboratory Features of Cases with Type 1 Diabetes Mellitus at Diagnosis. Turkish J Pediatr Dis 2018;12:173-9.
2. Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018;19:155-77.
3. Rewers A, Kuppermann N, Stoner MJ, Garro A, Bennett JE, Quayle KS, et al. Effects of fluid rehydration strategy on correction of acidosis and electrolyte abnormalities in children with diabetic ketoacidosis. Diabetes Care 2021;44:2061-8.
4. Kuppermann N, Ghetti S, Schunk JE, Stoner MJ, Rewers A, McManemy JK, et al. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. N Engl J Med 2018;378:2275-87.
5. Maurice L, Julliand S, Polak M, Bismuth E, Storey C, Renolleau S, et al. Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols. Eur J Pediatr 2022;181:1497-506.
6. Adrogué HJ, Wilson H, Boyd III AE, Suki WN, Eknoyan G. Plasma acid-base patterns in diabetic ketoacidosis. N Engl J Med 1982;307:1603-10.
7. Basnet S, Venepalli PK, Andoh J, Verhulst S, Koirala J. Effect of normal saline and half normal saline on serum electrolytes during recovery phase of diabetic ketoacidosis. J Intensive Care Med 2014;29:38-42.
8. Taylor D, Durward A, Tibby SM, Thorburn K, Holton F, Johnstone IC, et al. The influence of hyperchloraemia on acid base interpretation in diabetic ketoacidosis. Intensive Care Med 2006;32:295-301.

9. Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, et al. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014;15:154-79.
10. Ferreira JP, Hamui M, Torrents M, Carrano R, Ferraro M, Toledo I. The Influence of Chloride for the Interpretation of Plasma Bicarbonate During the Treatment of Diabetic Ketoacidosis. Pediatr Emerg Care 2020;36:e143-e45.
11. Chinoy A, Wright N, Bone M, Padidela R. Severe hypokalaemia in diabetic ketoacidosis: a contributor to central pontine myelinolysis? Endocrinol Diabetes Metab Case Rep 2019;2019:19-0034.
12. Palmer BF, Clegg DJ. Electrolyte and acid–base disturbances in patients with diabetes mellitus. N Engl J Med 2015;373:548-59.
13. Kardalas E, Paschou SA, Anagnostis P, Muscogiuri G, Siasos G, Vryonidou A. Hypokalemia: a clinical update. Endocr Connect 2018;7:R135-R46.
14. von Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. Diabetes Res Clin Pract 2018;135:76-84.
15. Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care 2009;22:172-7.
16. Chua H-R, Venkatesh B, Stachowski E, Schneider AG, Perkins K, Ladanyi S, et al. Plasma-Lyte 148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis. J Crit Care 2012;27:138-45.
17. Ramanan M, Attokaran A, Murray L, Bhadange N, Stewart D, Rajendran G, et al. Sodium chloride or Plasmalyte-148 evaluation in severe diabetic ketoacidosis (SCOPE-DKA): a cluster, crossover, randomized, controlled trial. Intensive Care Med 2021;47:1248-57.
18. Peeters E, Van Ijperen W, Robertson L, Royle P, van IJperen Sr W. Analysis of the safety and efficacy of diabetic ketoacidosis management in a Community General Hospital, 2001–2010: a descriptive study. Scott Med J 2015;60:121-5.
19. Naeem MA, Al-Alem HA, Al-Dubayee MS, Al-Juraibah FN, Omair A, Al-Ruwaili AS, et al. Characteristics of pediatric diabetic ketoacidosis patients in Saudi Arabia. Saudi Med J 2015;36:20-5.
20. Edge J, Nunney I, Dhatariya K. Diabetic ketoacidosis in an adolescent and young adult population in the UK in 2014: a national survey comparison of management in paediatric and adult settings. Diabet Med 2016;33:1352-9.
21. Rameshkumar R, Satheesh P, Jain P, Anbazhagan J, Abraham S, Subramani S, et al. Low-dose (0.05 Unit/kg/hour) vs standard-dose (0.1 Unit/kg/hour) insulin in the management of pediatric diabetic ketoacidosis: a randomized double-blind controlled trial. Indian Pediatr 2021;58:617-23.
22. Sehgal M, Batra M, Jha P, Sanchez O. Risk Factors and Laboratory Findings Associated With Diabetic Ketoacidosis in Hospitalized Pediatric Patients. Cureus 2022;14:e25410.
23. Karavanaki K, Karanika E, Georga S, Bartzeliotou A, Tsouvalas M, Konstantopoulos I, et al. Cytokine response to diabetic ketoacidosis (DKA) in children with type 1 diabetes (T1DM). Endocr J 2011;58:1045-3.
24. Xu W, Wu H-f, Ma S-g, Bai F, Hu W, Jin Y, et al. Correlation between peripheral white blood cell counts and hyperglycemic emergencies. Int J Med Sci 2013;10:758-65.
25. Abdel-Moneim A, Zanaty MI, El-Sayed A, Khalil RG, Rahman HA. Relation between oxidative stress and hematologic abnormalities in children with type 1 diabetes. Can J Diabetes 2020;44:222-8.