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. 2023 May 30:11:1198581.
doi: 10.3389/fped.2023.1198581. eCollection 2023.

The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis

Isaac Lazar #  1   2 , Dorit Wizeman-Orlov #  2 , Guy Hazan  2   3 , Asaf Orbach  1 , Alon Haim  2   3   4 , Yuval Cavari  1   2 , Yael Feinstein  1   2 , Eitan Neeman  1   2 , Eli Hershkovitz  2   3   4 , Yaniv Faingelernt  2   3
Affiliations

The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis

Isaac Lazar et al. Front Pediatr. .

Abstract

Introduction: Our aims were to determine whether anion gap normalization time (AGNT) correlates with risk factors related to the severity of diabetic ketoacidosis (DKA) in children, and to characterize AGNT as a criterion for DKA resolution in children admitted with moderate or severe disease.

Methods: A ten-year retrospective cohort study of children admitted to the intensive care unit with DKA. We used a survival analysis approach to determine changes in serum glucose, bicarbonate, pH, and anion gap following admission. Using multivariate analysis, we examined associations between patients' demographic and laboratory characteristics with delayed normalization of the anion gap.

Results: A total of 95 patients were analyzed. The median AGNT was 8 h. Delayed AGNT (>8 h) correlated with pH < 7.1 and serum glucose >500 mg/dL. In multivariate analysis, glucose >500 mg/dL was associated with an increased risk for delayed AGNT, by 3.41 fold. Each 25 mg/dL elevation in glucose was associated with a 10% increment in risk for delayed AGNT. Median AGNT preceded median PICU discharge by 15 h (8 vs. 23 h).

Discussion: AGNT represents a return to normal glucose-based physiology and an improvement in dehydration. The correlation observed between delayed AGNT and markers of DKA severity supports the usefulness of AGNT for assessing DKA recovery.

Keywords: DKA resolution; anion gap (AG); anion gap normalization time; children; diabetic ketoacidosis (DKA) - in children or adolescents with established type 1 diabetes; pediatric intensive care unit (PICU); type 1 diabetes mellitus (DM1).

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Flow chart of the study population. *Over 2-hour difference between serum chemistry and blood-gas results. **7 patients with AGNT >8hr. DKA, diabetic ketoacidosis; PICU, pediatric intensive care unit; EMR, electronic medical record; AGNT, anion gap normalization time; AG, anion gap.
Figure 2
Figure 2
The cumulative median anion gap normalization value according to time since admission. The Kaplan-Meier curve shows the cumulative median anion gap normalization value over time. The dotted line shows that for 50% of the population, the anion gap was normalized by the eighth-hour post-admission.
Figure 3
Figure 3
Median pH, bicarbonate, and anion gap values over the first 30 hours following admission. The three curves show changes in parameters in the 30 hours following admission. Diamonds (◊) represent median anion gap values, circles (○) represent median pH levels, and squares (□) represent median bicarbonate levels.
See this image and copyright information in PMC

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