The Prehospital Care of Diabetic Ketoacidosis in a Referral Hospital Pediatric Intensive Care Unit and the Utility of Telemedicine

Year 2023, Volume: 11 Issue: 3, 193 - 201, 15.10.2023

Merve Havan , Caner Turan , Mehmet İsakoca , Emel Hatun Aytaç Kaplan , Murat Ersoy

Abstract

Background/Aims: This study aimed to investigate the effects of the type of admission (ambulance/outpatient clinic) and telemedicine use in patients admitted to the pediatric intensive care unit (PICU) with diabetic ketoacidosis (DKA).
Material and Methods: A retrospective observational study designed in a referral PICU between January 2019 and December 2021. Demographic characteristics, type of admission (ambulance/outpatient clinic), the utility of telemedicine, clinical manifestations, and outcomes were recorded. The severity of the disease, complications, and length of stay in the PICU were compared between the groups (ambulance/outpatient and telemedicine applied/none-applied).
Results: 144 patients were included in the study. 51.4% of patients were male, and the median age was 13.0 years (range, 2-18 years). 45.1% of patients were transferred to the PICU by ambulance. Ambulance and telemedicine use was higher in newly diagnosed and younger age (p<0.001 and p=0.0014, respectively). Telemedicine was used in 56 (38.8%) patients. There was no significant difference in terms of Glasgow coma scale (13-13/13-13), PRISM III (8-9/9-8), mean HbA1c level (12.2-12.0), and complications (p= 0.35) at the time of admission between the groups that used and did not use ambulance and telemedicine. 66 (45.8%) patients did not develop any complications and there was no mortality in the study.
Conclusions: There is not enough data in the literature on the prehospital care of DKA patients admitted to PICU. Although there was no significant difference between prehospital care and outcomes in this study, we think that the low complication rate is related to telemedicine.

Keywords

Prehospital care, telemedicine, diabetic ketoacidosis, pediatric intensive care unit.

Ethical Statement

The study protocols were approved by the Mersin University Clinical Research Ethics Committee (Decision No: 2021/755, Date: 12/15/2021).

Supporting Institution

None

Thanks

All authors contributed to the study's conception and design. Material preparation, data collection, and analysis were performed by MH, CT, and ME. The manuscript was written by MH and CT. CT was responsible for statistical analyses. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Bir Sevk Hastanesindeki Çocuk Yoğun Bakım Ünitesinde Diyabetik Ketoasidozun Hastane Öncesi Bakımı ve Teletıpın Faydası

Abstract

Giriş: Bu çalışmada diyabetik ketoasidoz (DKA) nedeniyle çocuk yoğun bakım ünitesine (ÇYBÜ) başvuran hastalarda başvuru şeklinin (ambulans/poliklinik) ve teletıp kullanımının etkilerinin araştırılması amaçlandı.
Gereç ve Yöntem: Ocak 2019 ile Aralık 2021 tarihleri arasında ÇYBÜ'de DKA tanısı ile yatan hastaların incelendiği retrospektif gözlemsel bir çalışmadır. Demografik özellikler, başvuru türü (ambulans/ayakta tedavi kliniği), teletıp kullanımı, klinik bulgular ve sonuçlar kaydedildi. Gruplar (ambulans/ayakta tedavi ve teletıp uygulanan/uygulanmayan) arasında hastalığın şiddeti, komplikasyonları ve ÇYBÜ'de kalış süresi karşılaştırıldı.
Bulgular: Çalışmaya 144 hasta dahil edildi. Hastaların %51,4'ü erkekti ve ortanca yaş 13,0 yıldı (aralık, 2-18 yıl). Hastaların %45,1'i ambulansla ÇYBÜ'ye nakledildi. Ambulans ve teletıp kullanımı yeni tanı alan ve genç yaşta daha fazlaydı (sırasıyla p<0,001 ve p=0,0014). Hastaların 56'sında (%38,8) teletıp kullanıldı. Glasgow koma skalası (13-13/13-13), PRISM III (8-9/9-8), ortalama HbA1c düzeyi (12,2-12,0) ve komplikasyonlar (p= 0,35) açısından anlamlı fark yoktu. Ambulans ve teletıp kullanan ve kullanmayan gruplar arasında başvuru süreleri. 66 (%45,8) hastada herhangi bir komplikasyon gelişmedi ve çalışmada mortalite yaşanmadı.
Sonuç: ÇYBB'ye başvuran DKA'lı hastaların hastane öncesi bakımına ilişkin literatürde yeterli veri bulunmamaktadır. Bu çalışmada hastane öncesi bakım ve sonuçlar arasında anlamlı bir fark olmamasına rağmen komplikasyon oranının düşük olmasının teletıp ile ilgili olabileceğini düşünüyoruz.

Keywords

Hastane öncesi bakım, teletıp, diyabetik ketoasidoz, çocuk yoğun bakım ünitesi.

References

• 1- Kao KT, Islam N, Fox DA, et al. Incidence Trends of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes in British Columbia, Canada. J Pediatr 2020;221:165-173.
• 2- Cashen K, Petersen T. Diabetic Ketoacidosis. Pediatr Rev 2019;40(8):412-420.
• 3- Jensen ET, Stafford JM, Saydah S, et al. Increase in Prevalence of Diabetic Ketoacidosis at Diagnosis Among Youth With Type 1 Diabetes: The SEARCH for Diabetes in Youth Study. Diabetes Care 2021;44:1573-1578.
• 4- Glaser N, Fritsch M, Priyambada L, et al. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022;23:835-856.
• 5- Kamrath C, Mönkemöller K, Biester T, et al. Ketoacidosis in Children and Adolescents With Newly Diagnosed Type 1 Diabetes During the COVID-19 Pandemic in Germany. JAMA 2020;324:801-804.
• 6- Glaser N, Fritsch M, Priyambada L, et al. Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med 2001;344:264-269.
• 7- Castellanos L, Tuffaha M, Koren D, et al. Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus. Paediatr Drugs 2020;22:357-367.
• 8- Burke BL Jr, Hall RW. Telemedicine: Pediatric Applications. Pediatrics 2015;136:293-308.
• 9- Olson Ca, McSwain SD, CurfmanAL, et al. The Current Pediatric Telehealth Landscape. Pediatrics 2018;141:e20172334.
• 10- Pollack MM, Patel KM, Ruttimann UE. PRISM III: An updated pediatric risk of mortality score. Crit Care Med 1996;24:743–752.
• 11- Besli GE, Akyıldız BN, Ağın H, Anıl AB, Çıtak A, Duman M, Dursun O, Erkek N, Kalkan G, Kendirli T, Köroğlu TF, Öztürk N, Şevketoğlu E, Yıldızdaş D. Diyabetik Ketoasidoz Tedavi Protokolü. J Pediatr Emerg Intensive Care Med 2020;7(Suppl-1):74-90.
• 12- Lawrence JM, Divers J, Isom S, et al. Trends in prevalence of type 1 and type 2 diabetes in children and adolescents in the US, 2001–2017. JAMA 2021;326:717–727.
• 13- TeriSue Smith-Jackson, Mary V. Brown, Matthew Flint, et al. A Mixed Method Approach to Understanding the Factors Surrounding Delayed Diagnosis of Type One Diabetes. J Diabetes Complications 2018;32:1051-1055.
• 14- Elding Larsson H, Vehik K, et al. Reduced prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes in young children participating in longitudinal follow-up. Diabetes Care 2011;34:2347-2352.
• 15- Jackman J, Chafe R, Albrechtsons D, et al. Delayed diagnosis and issues with pump usage are the leading causes of diabetic ketoacidosis in children with diabetes living in Newfoundland and Labrador, Canada. BMC Res Notes 2015;8:158.
• 16- Koves IH, Leu MG, Spencer S, et al. Improving care for pediatric diabetic ketoacidosis. Pediatrics 2014;134:848–856.
• 17- Turan C, Yurtseven A, Basa EG, et al. The Effects of Prehospital Care on Outcome in Pediatric Diabetic Ketoacidosis. J Clin Res Pediatr Endocrinol. 2020;12:189-196.
• 18- Bradley P, Tobias JD. An evaluation of the outside therapy of diabetic ketoacidosis in pediatric patients. Am J Ther 2008;15:516-519.
• 19- Curfman A, McSwain SD, Chuo J, et al. Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond. Pediatrics 2021;148:e2020047795.
• 20- Curfman A, Groenendyk J, Markham C, et al. Implementation of Telemedicine in Pediatric and Neonatal Transport. Air Med J 2020;39:271-275.
• 21- Kaushal T, Tinsley LJ, Volkening LK, et al. Improved CGM Glucometrics and More Visits for Pediatric Type 1 Diabetes Using Telemedicine during 1 Year of COVID-19. J Clin Endocrinol Metab 2022;107:4197-4202.
• 22- Predieri B, Leo F, Candia F, et al. Glycemic Control Improvement in Italian Children and Adolescents With Type 1 Diabetes Followed Through Telemedicine During Lockdown Due to the Covid-19 Pandemic. Front Endocrinol (Lausanne) 2020;11:595735.
• 23- Shulman RM, O'Gorman CS, Palmert MR. The impact of telemedicine interventions involving routine transmission of blood glucose data with clinician feedback on metabolic control in youth with type 1 diabetes: a systematic review and meta-analysis. Int J Pediatr Endocrinol 2010;2010:536957.
• 24- Udsen FW, Hangaard S, Bender C, et al. The Effectiveness of Telemedicine Solutions in Type 1 Diabetes Management: Systematic Review and Meta-analyses. J Diabetes Sci Technol 2023;17:782-793.
• 25- Cobry EC, Reznick-Lipina T, Pyle L, et al. Diabetes Technology Use in Remote Pediatric Patients with Type 1 Diabetes Using Clinic-to-Clinic Telemedicine. Diabetes Technol Ther 2022;24:67-74.
• 26- Danne T, Limbert C, Puig Domingo M, et al. Telemonitoring, Telemedicine and Time in Range During the Pandemic: Paradigm Change for Diabetes Risk Management in the Post-COVID Future. Diabetes Ther. 2021;12(9):2289-2310.
• 27- Peters AL, Garg SK. The Silver Lining to COVID-19: Avoiding Diabetic Ketoacidosis Admissions with Telehealth. Diabetes Technol Ther. 2020 Jun;22(6):449-453.
• 28- Evin F, Er E, Ata A, et al. The Value of Telemedicine for the Follow-up of Patients with New Onset Type 1 Diabetes Mellitus During COVID-19 Pandemic in Turkey: A Report of Eight Cases. J Clin Res Pediatr Endocrinol 2021 Nov 25;13(4):468-472
• 29- Kiral E, Kirel B, Havan M, et al. Increased Severe Cases and New-Onset Type 1 Diabetes Among Children Presenting With Diabetic Ketoacidosis During First Year of COVID-19 Pandemic in Turkey. Front Pediatr 2022;10:926013.
• 30- Ampt A, van Gemert T, Craig ME, et al. Using population data to understand the epidemiology and risk factors for diabetic ketoacidosis in Australian children with Type 1 diabetes. Pediatr Diabetes 2019;20:901-908
• 31- Wojcik M, Sudacka M, Wasyl B, et al. Incidence of type 1 diabetes mellitus during 26 years of observation and prevalence of diabetic ketoacidosis in the later years. Eur J Pediatr 2015;174:1319-1324.
• 32- Jefferies C, Cutfield SW, Derraik JG, et al.15-year incidence of diabetic ketoacidosis at onset of type 1 diabetes in children from a regional setting (Auckland, New Zealand). Sci Rep 2015;5:10358.