A review of the efficacy of the Milwaukee Protocol in the treatment of ketoacidosis in pediatric intensive care unit patients at Rebro Hospital between 2009-2014

master's thesis

• Author: Mohammad Imran Khan Malik
• Mentor: Mario Ćuk (mentor)
• Committee member: Danko Milošević (predsjednik povjerenstva)
• Committee member: Marija Jelušić (član povjerenstva)
• Committee member: Mario Ćuk (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; Zagreb
• Defense date and country: 2015-01-30, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Pediatrics

Abstract

Ketoacidosis is a condition of increased pathologic levels of ketone bodies in the body that results in the acidification of blood. The major types are alcoholic and diabetic ketoacidosis. DKA is defined as an arterial pH < 7.25, serum bicarbonate < 15mEq/L and elevated ketones in serum or urine (Marcdante et al. 2010). Other sources define DKA with the above criteria but also additionally a glucose concentration >11mmol/L (>200mg/dL) together with glucosuria and ketouria (Rosenbloom 2010) (Wolfsdorf et al. 2009). Paediatric patients reviewed at Rebro Hospital (University Hospital Centre Zagreb) were all treated for the latter condition. This thesis surmises the treatment methodology as devised by the Milwaukee Protocol and attempts to evaluate the efficacy of this treatment over the period of 01.01.2009 – 30.06.2014. Patient records were obtained from the Rebro Hospital archives and details on ICU treatment of diabetic ketoacidosis were evaluated. Personal identifying data was removed. During the period analysed patient archive records indicate that 21 patients were admitted into the paediatric ICU at University Hospital Centre Zagreb for treatment of DKA. 20 patient records were obtained, of which 19 patients were confirmed to have been treated according to the Milwaukee protocol. It was assumed that the other 2 cases were as well as it is the hospital policy to follow this protocol. Successful treatment was observed in 100% of cases. Success is defined here as the sufficient control of the metabolic derangement as indicated by meeting the following Milwaukee Protocol exit criteria: HCO3 > 15 mmol/l, pH 2 > 7.30, Na: 135-145 mmol/l with no emesis (Kliegman et al. 2011) and resulting in discharge of patient from ICU. Conclusions drawn include the need for a coordinated response based on a hospital wide policy with clear pro forma. Management of DKA condition should be under the supervision of centres that have experience dealing with the issue; at University hospital Zagreb (Rebro hospital) this should be the paediatric ICU centre. Vital signs, neurologic status and laboratory indices for DKA biomarkers should be monitored at timely intervals as to prevent further adverse effects. It is suggested that data be recorded electronically and on ICU forms designed to record DKA. In cases of cerebral oedema, Rebro hospital should develop protocols to be able to identify CE development early on and treat rapidly with mannitol or hypertonic IV saline. With respect to treatment fluid resuscitation should begin before intravenous insulin administration (0.1. U/Kg/hr), beginning with a bolus of 10-20mL/kg 0.9% saline, followed by a maintenance supply of 0.45% saline that should address 5-10% of fluid loss from dehydration (Rosenbloom 2010) (Kliegman et al. 2011).

• Keywords: Diabetic Ketoacidosis (DKA); Milwaukee Protocol; cerebral oedema; children; prevention; treatment
• Language: english
• URN:NBN: urn:nbn:hr:105:829603
• Study programme: Title: Medicine (in English language); Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2015-12-09 12:09:58