Outcomes of children with severe diabetic ketoacidosis managed outside of a pediatric intensive care unit

Objectives: Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes. Our objective was to determine if children with severe DKA without alteration in mental status can be managed safely on a general children's medical unit. Methods: Single center retrospective study of 191 patient encounters among 168 children admitted to the children's medical unit (CMU) at Primary Children's Hospital between 2007 and 2017 with severe DKA (pH < 7.1 and/or bicarbonate < 5 mmol/L). Chart review identified complications including death, transfer to the intensive care unit (ICU), incidence of cerebral edema, and hypoglycemia. We compared patients requiring ICU transfer with those who did not with respect to demographics, laboratory findings at presentation, therapeutic interventions, length of stay, and cost. Results: Of 191 patient encounters, there were 0 deaths (0%, 95% CI 0-2.4%), 22 episodes of alteration of mental status concerning for developing cerebral edema (11.5%, 95% CI 7.7-16.9%), 19 ICU transfers (10%, 95% CI 6.4-15.1%), and 7 episodes of hypoglycemia (3.7%, 95% CI 1.6-7.5%). ICU transfer was associated lower initial pH (7.03 +/- 0.06 vs. 7.07 +/-; 0.07, p < 0.05), increased length of stay (3.0 +/- 0.8 vs. 2.2 +/- 0.9 days, p < 0.05), and increased cost of hospitalization (mean +/- SD $8,073 +/- 2,042 vs. $5,217 +/- 1,697, p < 0.05). Conclusions: The majority of children with severe DKA without alteration in mental status can be managed safely on a medical unit. Implementing a pH cutoff may identify high-risk patients that require ICU level of care.