Glaser N S, Kuppermann N, Yee C K, Schwartz D L, Styne D M
Department of Pediatrics, University of California, Davis, School of Medicine, Sacramento, USA.
Arch Pediatr Adolesc Med. 1997 Nov;151(11):1125-32. doi: 10.1001/archpedi.1997.02170480055008.
To compare management strategies for pediatric diabetic ketoacidosis (DKA) among physicians with different specialty training.
We conducted a mail survey of 1000 randomly selected physicians, including 200 pediatric endocrinologists, 200 general emergency physicians, 200 pediatric emergency physicians, 200 pediatric intensivists, and 200 pediatric chief residents. We posed questions regarding a hypothetical 10-year-old patient with new onset of diabetes mellitus who is approximately 10% dehydrated but alert, with venous pH of 7.1 and serum glucose concentration of 34.7 mmol/L (625 mg/dL). Questions involved the rate of rehydration, content of intravenous fluids, insulin therapy, potassium replacement, use of sodium bicarbonate, and adjustments in therapy for decreasing serum glucose concentration. We compared responses of physicians in each specialty and used multiple regression analysis to adjust for potential confounding variables, including number of years in practice, number of children with DKA seen per month, and practice setting.
Five hundred eighty-one physicians (58.1%) completed the survey, with responses demonstrating significant, consistent differences between specialties. Extremes of responses included the following: (1) 59% of endocrinologists vs 11% of general emergency physicians would give an initial fluid bolus of less than 20 mL/kg (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.0-27.7) (P < .001); (2) 83.5% of general emergency physicians vs 42.5% of pediatric intensivists would administer an initial insulin bolus (OR, 4.1; 95% CI, 2.0-8.7) (P < .001); (3) 58.2% of pediatric intensivists vs 9% of general emergency physicians would replace fluids over a period of greater than 24 hours (OR, 14.1; 95% CI, 5.5-37.5) (P < .001); and (4) 54.3% of general emergency physicians vs 7.3% of pediatric intensivists would use potassium chloride alone for potassium replacement (OR, 10.8; 95% CI, 5.0-23.8) (P < .001). All of these differences persisted after adjusting for the potential confounding variables.
Substantial differences exist in the management of pediatric DKA among physicians of different specialties, presumably due to differences in specialty training. These differences obscure our ability to evaluate the treatment of DKA and highlight the necessity for further studies comparing the outcomes of different treatment strategies.
比较接受不同专业培训的医生对儿童糖尿病酮症酸中毒（DKA）的管理策略。
我们对1000名随机挑选的医生进行了邮件调查，其中包括200名儿科内分泌学家、200名普通急诊科医生、200名儿科急诊科医生、200名儿科重症监护医生和200名儿科住院总医师。我们提出了一些问题，涉及一名假设的10岁新发糖尿病患者，该患者约有10%的脱水但意识清醒，静脉血pH值为7.1，血清葡萄糖浓度为34.7 mmol/L（625 mg/dL）。问题包括补液速度、静脉输液的成分、胰岛素治疗、钾补充、碳酸氢钠的使用以及降低血清葡萄糖浓度的治疗调整。我们比较了各专业医生的回答，并使用多元回归分析来调整潜在的混杂变量，包括从业年限、每月诊治的DKA患儿数量和执业环境。
581名医生（58.1%）完成了调查，各专业之间的回答显示出显著且一致的差异。回答的极端情况包括：（1）59%的内分泌学家与11%的普通急诊科医生会给予初始静脉推注量小于20 mL/kg（比值比[OR]，11.7；95%置信区间[CI]，5.0 - 27.7）（P <.001）；（2）83.5%的普通急诊科医生与42.5%的儿科重症监护医生会给予初始胰岛素推注（OR，4.1；95% CI，2.0 - 8.7）（P <.001）；（3）58.2%的儿科重症监护医生与9%的普通急诊科医生会在超过24小时的时间段内补充液体（OR，14.1；95% CI，5.5 - 37.5）（P <.001）；以及（4）54.3%的普通急诊科医生与7.3%的儿科重症监护医生会单独使用氯化钾进行钾补充（OR，10.8；95% CI，5.0 - 23.8）（P <.001）。在调整潜在的混杂变量后，所有这些差异仍然存在。
不同专业的医生在儿童DKA的管理上存在显著差异，推测是由于专业培训的差异。这些差异模糊了我们评估DKA治疗的能力，并突出了进一步研究比较不同治疗策略结果的必要性。
