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Home , Ketoacidosis

BRIEF REPORT

The Accuracy of Clinical Assessment of During in Childhood

1 1 ILDIKO H. KOVES, MD GEORGE A. WERTHER, MD hydration categories as those used for the 2 2 JOCELYN NEUTZE, MD PETER BARNETT, MD doctors’ assessments. 3 1 SUSAN DONATH, MA FERGUS J. CAMERON, MD 1 WARREN LEE, MD Statistical analysis Agreement between the doctor’s assess- ments of dehydration and between as- sessed and measured dehydration were Ͻ he objective of this study was to ex- were pH 7.30 (capillary, venous, or ar- evaluated using ␬-statistics (5). amine the accuracy of the assess- terial) and/or bicarbonate Ͻ15 mmol/l T ment of clinical dehydration in and in the urine on dipstick test- children with and diabetic ing. The following information was re- RESULTS — The greatest number of ketoacidosis (DKA). DKA remains the sin- corded by the primary assessing doctor: patients (18 of 37) were between 5 and gle most common cause of diabetes- newly diagnosed or established diabetes, 10% dehydrated at presentation (as related death in childhood (1). Accurate age, sex, date and time seen, heart rate, calculated by their weight gains), with assessment and management of dehydra- respiratory rate, blood pressure, pale a median absolute measure of 8.7% tion is the cornerstone of DKA treatment and/or cool hands and feet, peripheral dehydration. (1,2). The assessment of the degree of capillary refill time, reduced skin turgor, There was a good level of agreement dehydration has traditionally been ac- level of consciousness (on a rating scale of between the primary and secondary as- cording to clinical criteria including pe- one to eight), sunken eyes, sunken fonta- sessor (␬ϭ0.5). There was agreement ripheral tissue perfusion and indicators of nelle, dry tongue, Kussmaul breathing, between assessors as to the degree of hemodynamic status (3). The clinical as- blood level, and estimated degree dehydration in 28 of 37 patients. Of the sessment of dehydration in children in of dehydration (clinical assessment). A remaining nine patients, there was dis- common nonacidotic states (e.g., gastro- second emergency department doctor, agreement of the amount of dehydration enteritis) has been previously shown (4) who was blinded to the clinical interpre- of 3% in eight patients and 6% in only one to overestimate the degree of dehydration tations of the primary doctor, was asked patient. by ϳ3.2%. There have been no compa- to review the patient before treatment in There was no agreement between as- rable studies in either DKA or any other the emergency department and record sessed and measured dehydration (␬ϭ form of metabolic . their assessment of the same clinical vari- 0.05) (Fig. 1). In patients who were Ͻ6% ables. Both doctors were asked to grade dehydrated (measured), the trend was to dehydration by category (0–2, 3–6, 7–9, overestimate dehydration, whereas in pa- RESEARCH DESIGN AND 10–12, and Ͼ12%). tients Ͼ6% dehydrated (measured), the METHODS — We studied a random Following admission, nursing staff re- trend was to underestimate dehydration. convenience sample of 37 children with corded daily weights until discharge. The Seventy percent (26 of 37) of the patients type 1 diabetes, newly or previously diag- absolute degree of dehydration was calcu- had their hydration status incorrectly as- nosed, who presented to the Royal Chil- lated from the weight gain from admis- sessed (24% [9 of 37] overestimated and dren’s Hospital, Melbourne, with DKA. sion to discharge as a percentage of the 46% [17 of 37] underestimated). The patients were all Ͻ18 years of age and child’s rehydrated weight. For patients Among both the newly diagnosed presented to the emergency department admitted for Ն5 days, the average weight DKA patients and those with DKA and at Royal Children’s Hospital between of days 4–6 was used. Measured dehy- established diabetes, none of the clinical 1996 and 2000. The study entry criteria dration was converted into the same de- variables measured by primary and sec- ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● ondary assessors or biochemical variables From the 1Centre for Hormone Research, Murdoch Children’s Research Institute, Royal Children’s Hospital had a statistically significant independent Melbourne, Melbourne, Australia; the 2Emergency Department, Murdoch Children’s Research Institute, association with the degree of measured Royal Children’s Hospital Melbourne, Melbourne, Australia; and the 3Clinical Epidemiology and Biostatistics absolute dehydration. Unit, Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, Melbourne, Australia. Address correspondence and reprint requests to Dr. Fergus Cameron, Deputy Director, Department of and Diabetes, Royal Children’s Hospital, Flemington Road, Parkville, 3052, Melbourne, Australia. E-mail: [email protected]. CONCLUSIONS — Accurate hydra- Received for publication 24 June 2004 and accepted in revised form 2 July 2004. tion assessment is critical in DKA man- Abbreviations: DKA, diabetic ketoacidosis. A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion agement. It is a contentious issue whether factors for many substances. overzealous rehydration may contribute © 2004 by the American Diabetes Association. to cerebral edema in children with DKA

DIABETES CARE, VOLUME 27, NUMBER 10, OCTOBER 2004 2485 Dehydration during DKA in childhood

Figure 1—The relationship between es- timated (by doctor 1) and measured de- hydration, grouped into five categories.

(2,6,7). Conventional clinical assessment traditional clinical signs of dehydration tween the potentially catastrophic risks of of the degree of dehydration is based on are poor tools in other nonacidotic condi- overhydration compared with the lesser numerous clinical signs and symptoms tions such as gastroenteritis. Mackenzie et risks of prolonged mild underhydration. (8) and mostly assesses the depletion of al. (4) found that in pediatric patients Rehydration should take place over a extracellular fluid volume. The assess- with gastroenteritis the four signs that 48-h period, with normal or half-normal ment of dehydration in DKA is compli- best predicted dehydration were capillary saline and adequate potassium replace- cated by extra- and intravascular refill time Ͼ2 s, absent tears, dry mucous ment. Ongoing therapy should of course dehydration, affecting membranes, and overall appearance of ill- include estimates of continuing fluid loss the clinical signs of dehydration, and the ness. Murphy et al. (11) found that the and electrolyte status as recommended by overall catabolic state of the patient. Met- most valuable signs of assessing dehydra- the recent ESPE/LWPES (European Soci- abolic acidosis can cause a decrease in pe- tion in gastroenteritis were decreased skin ety for Paediatric Endocrinology/Lawson ripheral vascular resistance, a decrease in turgor, dry oral mucosa, sunken eyes, and Wilkins Pediatric Endocrine Society) cardiac ventricular function, and com- altered neurological status. None of these guidelines (14). pensatory hyperventilation (9). Pro- clinical parameters were found to be good longed deficiency is associated predictors in our study of DKA. with lipolysis and proteolysis and subse- The previous assumption of an aver- References quent weight loss. All of these indepen- age overall 10% dehydration in patients 1. Edge JA, Ford-Adams ME, Dunger DB: dent effects may interfere with the clinical with DKA (3,12,13) appears to be a slight Causes of death in children with insulin assessment of dehydration. Thus in pa- overestimate. The median absolute mea- dependent diabetes 1990–96. Arch Dis tients presenting with DKA, the signs of sure of dehydration as calculated by our Child 81:318–323, 1999 hemodynamic stability (heart rate and patients’ weight gain was 8.7%. Given 2. Carlotti AP, Bohn D, Halperin ML: Impor- blood pressure), capillary refill, tissue tur- that clinical hydration assessment ap- tance of timing of risk factors for cerebral oedema during therapy for diabetic keto- gor, moistness of oral mucous mem- pears to be unreliable when compared acidosis. Arch Dis Child 88:170–173, 2003 branes, and degree of weight loss may not with absolute measures of dehydration 3. Rosenbloom AL: Diabetic ketoacidosis: be indicative of only fluid losses per se. and that no single clinical parameter ap- treatment guidelines. Clin Paediatr 35: In our study the discrepancy between pears to be of benefit, we feel that a con- 261–266, 1996 estimated and true dehydration appears servative empirical approach may be 4. Mackenzie A, Barnes G, Shann F: Clinical to be an operator-independent phenome- advocated. Initial bolus therapy of 10–20 signs of dehydration in children. Lancet non. Our data show good agreement be- ml/kg body wt of normal saline should be 2:605–607, 1989 tween the two independent assessing given until the patient is normotensive, 5. Cohen J: A coefficient of agreement for doctors. This is presumably a reflection of with ongoing meticulous care and fre- nominal scales. Educ Psychol Meas 20:37– the consistency in the training and prac- quent observations of hemodynamic sta- 46, 1960 6. Edge JA: Cerebral oedema during treat- tice of our medical staff in assessing clin- tus. Thereafter, an initial assumption of ment of diabetic ketoacidosis: are we any ical hydration. Unfortunately, in the 7–9% dehydration seems a reasonable nearer finding a cause? Diabetes Metab Res clinical context of DKA, such training and figure upon which to base rehydration Rev 16:316–324, 2000 practice appears to be erroneous. Other calculations in most patients. This esti- 7. Glaser N, Barnett P, McCaslin I, Nelson D, studies (4,10,11) have suggested that the mate may be the best compromise be- Trainor J, Louie J: Risk factors for cerebral

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edema in children with diabetic ketoaci- 10. Brewster DR: Dehydration in acute gas- of diabetic ketoacidosis in children and dosis. N Engl J Med 344:264–269, 2001 troenteritis. J Paeds Child Health 38:219– young adults. Prim Care 10:663– 662, 8. Lapides J, Bourne RB, MacLean LR: Clin- 222, 2002 1983 ical signs of dehydration and extracellular 11. Murphy MS: Guidelines for managing 14. Dunger DB, Sperling MA, Acerini CL, fluid loss. JAMA 191:141–143, 1965 acute gastroenteritis based on a systematic Bohn DJ, Daneman D, Danne TP, Glaser 9. Adelman RD, Solhaug MJ, Sperling MA: review of published research. Arch Dis NS, Hanas R, Hintz RL, Levitsky LL, Sav- Pathophysiology of body fluids and fluid Child 79:279–284, 1998 age MO, Tasker RC, Wolfsdorf JI, ESPE, therapy. In Nelson Textbook of Pediatrics. 12. Schade DS, Eaton RP: Diabetic ketoacido- LWPES: ESPE/LWPES consensus state- 16th ed. Behrman RE, Kliegman RM, sis-pathogenesis, prevention and therapy. ment on diabetic ketoacidosis in children Jenson HB, Eds. Philadelphia, Saunders, Clin Endocrinol Metab 12:321–338, 1983 and adolescents. Arch Dis Child 89:188– 2000, p. 189–227 13. Schwenk WF, Haymond MW: Treatment 194, 2004

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