Clinical and Laboratory Predictors of Dehydration Severity in Children With Diabetic Ketoacidosis - 19/07/23
Doi : 10.1016/j.annemergmed.2023.01.001
Jennifer L. Trainor, MD a, ⁎ 
, Nicole S. Glaser, MD b, Leah Tzimenatos, MD c, Michael J. Stoner, MD d, Kathleen M. Brown, MD e, Julie K. McManemy, MD, MPH f, Jeffrey E. Schunk, MD g, Kimberly S. Quayle, MD h, Lise E. Nigrovic, MD, MPH i, Arleta Rewers, MD, PhD j, Sage R. Myers, MD, MSCE k, Jonathan E. Bennett, MD l, Maria Y. Kwok, MD, MPH m, Cody S. Olsen, MS g, T. Charles Casper, PhD g, Simona Ghetti, PhD n, Nathan Kuppermann, MD, MPH b, c
on behalf of the
, Nicole S. Glaser, MD b, Leah Tzimenatos, MD c, Michael J. Stoner, MD d, Kathleen M. Brown, MD e, Julie K. McManemy, MD, MPH f, Jeffrey E. Schunk, MD g, Kimberly S. Quayle, MD h, Lise E. Nigrovic, MD, MPH i, Arleta Rewers, MD, PhD j, Sage R. Myers, MD, MSCE k, Jonathan E. Bennett, MD l, Maria Y. Kwok, MD, MPH m, Cody S. Olsen, MS g, T. Charles Casper, PhD g, Simona Ghetti, PhD n, Nathan Kuppermann, MD, MPH b, con behalf of the
Pediatric Emergency Care Applied Research Network (PECARN) FLUID Study Group†
Clinton S. Perry, PhD, James P. Marcin, MD, MPH, Mary Murray, MD, Jared Henricksen, MD, Brad Poss, MD, J. Michael Dean, MD, MB, Bema Bonsu, MD, Tensing Maa, MD, Justin Indyk, MD, PhD, Marian Rewers, MD, PhD, Peter Mourani, MD, Jake A. Kushner, MD, Laura L. Loftis, MD, Monika Goyal, MD, MSCE, Rakesh Mistry, MD, MS, Vijay Srinivasan, MD, Andrew Palladino, MD, Colin Hawkes, MD, Joseph I. Wolfsdorf, MD, Michael S. Agus, MD, Linda Snelling, MD, Charlotte Boney, MD, MS, Fran R. Cogen, MD, CDE, Sonali Basu, MD, Neil H. White, MD, CDE, Nikoleta S. Kolovos, MD, Donald Zimmerman, MD, Denise Goodman, MD, MS, Andrew D. DePiero, MD, Daniel A. Doyle, MD, Meg A. Frizzola, MD, Scott Baird, MD, David Schnadower, MD
a Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
b Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
c Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
d Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH
e Division of Emergency Medicine, Department of Pediatrics, Children’s National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC
f Division of Emergency Medicine; Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
g Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, (UT)
h Division of Emergency Medicine, Department of Pediatrics, St. Louis Children’s Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
i Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
j Division of Emergency Medicine, Department of Pediatrics, Colorado Children’s Hospital, University of Colorado–Denver School of Medicine, Aurora, CO
k Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
l Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
m Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University College of Physicians and Surgeons, New York, NY
n Department of Psychology, and the Center for Mind and Brain, University of California Davis, Davis, CA
∗Corresponding Author.
Abstract |
Study objective |
Our primary objective was to characterize the degree of dehydration in children with diabetic ketoacidosis (DKA) and identify physical examination and biochemical factors associated with dehydration severity. Secondary objectives included describing relationships between dehydration severity and other clinical outcomes.
Methods |
In this cohort study, we analyzed data from 753 children with 811 episodes of DKA in the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation Study, a randomized clinical trial of fluid resuscitation protocols for children with DKA. We used multivariable regression analyses to identify physical examination and biochemical factors associated with dehydration severity, and we described associations between dehydration severity and DKA outcomes.
Results |
Mean dehydration was 5.7% (SD 3.6%). Mild (0 to <5%), moderate (5 to <10%), and severe (≥10%) dehydration were observed in 47% (N=379), 42% (N=343), and 11% (N=89) of episodes, respectively. In multivariable analyses, more severe dehydration was associated with new onset of diabetes, higher blood urea nitrogen, lower pH, higher anion gap, and diastolic hypertension. However, there was substantial overlap in these variables between dehydration groups. The mean length of hospital stay was longer for patients with moderate and severe dehydration, both in new onset and established diabetes.
Conclusion |
Most children with DKA have mild-to-moderate dehydration. Although biochemical measures were more closely associated with the severity of dehydration than clinical assessments, neither were sufficiently predictive to inform rehydration practice.
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| Please see page 168 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editor is available at editors. |
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| Author contributions: Dr. Trainor conceptualized and designed the study, supervised, acquired, analyzed, and interpreted the data, and drafted and critically revised the manuscript for important intellectual content. Dr. Glaser obtained funding, conceptualized, and designed the study, supervised, acquired, analyzed, and interpreted the data, drafted and critically revised the manuscript for important intellectual content. Dr. Kuppermann obtained funding, conceptualized, and designed the study, supervised, acquired, analyzed, and interpreted the data, drafted and critically revised the manuscript for important intellectual content, and provided administrative, technical, and material support. Mr. Olsen and Dr. Casper conceptualized and designed the study, had full access to all the data, took responsibility for the integrity of the data and the accuracy of the data analysis, drafted portions of the manuscript, and critically revised the manuscript for important intellectual content. Drs. Tzimenatos, Stoner, Brown, McManemy, Schunk, Quayle, Nigrovic, Rewers, Myers, Bennett, Kwok, and Ghetti conceptualized and designed the study, supervised, acquired, analyzed, and interpreted the data, and critically revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Dr. Trainor takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Kuppermann reported receiving personal fees from InsuCalc outside the submitted work. The rest of the authors do not have any conflict of interest to declare. This study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (grant No. U01HD062417) and Emergency Medical Services for Children Network Development Demonstration Program of the Maternal and Child Health Bureau, Health Resources and Services Administration, under a cooperative agreement (awards U03MC00008, U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC22684, and U03MC22685). |
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| Trial Registration Number: NCT00629707. |
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| Meetings: Portions of this work were presented virtually at the American Academy of Pediatrics National Conference and Exhibition in October 2020 and the Pediatric Academic Societies meeting in May 2021. |
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| Disclosures: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The content and conclusions of this article are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Health Resources and Services Administration, the Department of Health and Human Services, or the US government. |
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© 2023
American College of Emergency Physicians. Publié par Elsevier Masson SAS. Tous droits réservés.
Vol 82 - N° 2
P. 167-178 - août 2023 Retour au numéro
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