576 - Transient worsening of acidosis among children with diabetic ketoacidosis

Publication Number: 576.6609

Kayla Rodriguez, The Children's Hospital at Montefiore, Bayside, NY, United States; Friedman Benjamin, The Children's Hospital at Montefiore, Bronx, NY, United States; Aimee Belak, Cohen Children's Medical Center, BRONXVILLE, NY, United States; hnin Khine, Albert Einstein College of Medicine, Pelham Manor, NY, United States

Background: Normal saline is usually used in the resuscitation of children with Diabetic Ketoacidosis (DKA). Transient worsening of acidosis (TWA) after normal saline bolus has been observed in these patients. TWA is thought to be related to worsening of lactic acidosis secondary to redistribution of lactic acid during rehydration. The relative contribution of hyperchloremic metabolic acidosis is unclear.

Objective: The objectives of this study are 1) to determine the frequency of TWA 2) to determine whether worsening of lactic acidosis versus hyperchloremia is a better explanation of TWA.

Design/Methods: This is a retrospective study of patients aged 0 to 21 years old who presented to the Pediatric Emergency Department at a quaternary care hospital for management of DKA between January 2019 – December 2022. Patients who had a diagnosis of DKA were eligible for the study. Each included patient had 1 venous blood gas with lactate levels pre-bolus, one post-bolus, and a minimum of one basic metabolic panel during that period. To limit potential bias, only one encounter per patient was included in the study. We defined TWA as post bolus pH - baseline pH < 0. We compared age, mean changes in lactate, and chloride between the group with TWA and the non-TWA group using t-tests. We compared sex using chi-square.

Results: 632 encounters were identified. 492 were excluded (103 = care initiated outside of quaternary care center, 195 = absence of DKA, 194 = type 2 diabetes) leaving 140 for analysis. The median age of study population was 13 years (25th%-9, 75th%-17 years). 39% were male. The mean pH of the patients on arrival was 7.13 (SD 0.10). Overall, there were 68/140 (48.6%) with TWA. There was no difference between TWA and non-TWA groups for age (p=0.33) or sex (p=0.10). The mean initial lactate level was 3.29 (SD 1.91). The mean second lactate level after bolus was 2.71 (SD 1.60). Both TWA group and non-TWA had an improvement in lactic acid post rehydration, however the improvement was greater in non-TWA group (TWA 0.23 SD 0.90 vs non-TWA 0.97 SD 1.18) p< 0.01. Mean chloride on presentation was 98.9 (SD=6.2, N=139). Mean second chloride was 104.9 SD 6.0, N=83. Post bolus, the mean chloride in the TWA group was 104.5 (SD 6.2) vs 105.3 (SD 5.9) in the non-TWA group (p=0.56).

Conclusion(s): Nearly half of children who are treated for DKA have worsening of acidosis after normal saline bolus. There is no evidence of worsening lactic acidosis or hyperchloremia post bolus to attribute to TWA.