Variation in the management of pediatric diabetic ketoacidosis by specialty training
N. S. Glaser, N. Kuppermann, C. K. Yee, D. L. Schwartz and D. M. Styne
Department of Pediatrics, University of California, Davis, School of Medicine, Sacramento, USA. nsglaser@ucdavis.edu
OBJECTIVE: To compare management strategies for pediatric diabetic
ketoacidosis (DKA) among physicians with different specialty training.
METHODS: We conducted a mail survey of 1000 randomly selected physicians,
including 200 pediatric endocrinologists, 200 general emergency physicians,
200 pediatric emergency physicians, 200 pediatric intensivists, and 200
pediatric chief residents. We posed questions regarding a hypothetical
10-year-old patient with new onset of diabetes mellitus who is
approximately 10% dehydrated but alert, with venous pH of 7.1 and serum
glucose concentration of 34.7 mmol/L (625 mg/dL). Questions involved the
rate of rehydration, content of intravenous fluids, insulin therapy,
potassium replacement, use of sodium bicarbonate, and adjustments in
therapy for decreasing serum glucose concentration. We compared responses
of physicians in each specialty and used multiple regression analysis to
adjust for potential confounding variables, including number of years in
practice, number of children with DKA seen per month, and practice setting.
RESULTS: Five hundred eighty-one physicians (58.1%) completed the survey,
with responses demonstrating significant, consistent differences between
specialties. Extremes of responses included the following: (1) 59% of
endocrinologists vs 11% of general emergency physicians would give an
initial fluid bolus of less than 20 mL/kg (odds ratio [OR], 11.7; 95%
confidence interval [CI], 5.0-27.7) (P < .001); (2) 83.5% of general
emergency physicians vs 42.5% of pediatric intensivists would administer an
initial insulin bolus (OR, 4.1; 95% CI, 2.0-8.7) (P < .001); (3) 58.2%
of pediatric intensivists vs 9% of general emergency physicians would
replace fluids over a period of greater than 24 hours (OR, 14.1; 95% CI,
5.5-37.5) (P < .001); and (4) 54.3% of general emergency physicians vs
7.3% of pediatric intensivists would use potassium chloride alone for
potassium replacement (OR, 10.8; 95% CI, 5.0-23.8) (P < .001). All of
these differences persisted after adjusting for the potential confounding
variables. CONCLUSIONS: Substantial differences exist in the management of
pediatric DKA among physicians of different specialties, presumably due to
differences in specialty training. These differences obscure our ability to
evaluate the treatment of DKA and highlight the necessity for further
studies comparing the outcomes of different treatment strategies.
