Undetermined complexity of the pathophysiology of diabetic ketoacidosis in undernourished children.

338 www.pccmjournal. org March 2013 • Volume 14 • Number 3 Undetermined Complexity of the Pathophysiology of Diabetic Ketoacidosis in Undernourished Children To the Editor: I write with reference to the study of nutritional status and complications in children with diabetic ketoacidosis (DKA) by Moulik et al (1) published recently in Pediatric Critical Care Medicine. First, the authors used the criteria of weight matched for age and sex from the published Indian standards to classify their subjects as undernourished (less than the third centile) and normal nourished (more than the third centile). However, it is intriguing that nearly three fourth patients in “normally nourished” group still had mid-upper-arm circumference below mean-for-age and that the prevalence of hypovitaminosis-A was three times higher in the “normally nourished” group. Furthermore, nearly 60% in normally nourished group had hypoalbuminemia. These observations suggest that the two groups were probably not mutually exclusive in the true sense. The appreciable overlap in the nutritional deficiency status (e.g., low serum albumin) between the two groups could well have obscured the possible underlying clinically significant factors which could have affected the outcomes. Furthermore, children falling above the third centile could also be overweight or obese and therefore inclusion of body mass index in the assessDOI: 10.1097/PCC.0b013e3182760748 Mavilde da Luz Gonçalves Pedreira, RN, PhD, Maria Angélica Sorgini Peterlini, RN, PhD, Priscilla Sete de Carvalho Onofre, RN, MSc, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil assessments performed by each trained nurse. We understand the uncertainties that this new nursing approach can introduce into the appraisal of the obtained results, and we decided to describe this issue—the nurses’ experience with ultrasound— as another study limitation. Nevertheless, as noted in Table 3, the majority of the nurses were capable of assessing images in accordance with the technological capability of the ultrasound equipment used in our study, a 25-mm, 10to 15-mHz linear array transducer reaching a 4-cm depth. The duration of the procedure was taken to be the time spent on the procedure in minutes and was measured using a digital chronometer, starting at the time of skin preparation and ending at the time of the completion of placing the dressing over the insertion site. This time period was used for both groups, as described in the Methods section of the article. As noted by Gaspar et al (1), some factors were not included in our study due to the difficulty in deciding which variables to present in the final report. We chose the variables that provided the best scientific support for the objectives of the study. All of the addressed limitations are presented and discussed below. According to the primary data, the majority of patients were submitted to major or prolonged surgical procedures (71.4% in the Ultrasound Group [UG]; 90.5% in the Control Group [CG]; p = 0.238) and presented with a congenital or chronic disease (UG 71.4%; CG 76.2%; p = 0.726) that required critical or semicritical care at some point during hospitalization. The veins of all children were clinically assessed, and the majority were classified as palpable and visible in the left arm (UG 76.2%; CG 76.2%; p = 1.000) and in the right arm (UG 71.4%; CG 90.5%; p = 0.238), but the majority of children in both groups (p = 0.443) had a history of previous local complications of IV therapy, such as hematoma (p = 0.999), infiltration (p = 0.469), and phlebitis (p = 0.999). Late complications of IV therapy such as phlebitis and infection were not the subject of this placement study, but we performed a follow up of all children. None developed PICC-associated bloodstream infections, but 12 (28.5%) PICC were removed due to adverse events, with no differences between groups (p = 0.999). The adverse events were catheter obstruction (UG 14.3%; CG 4.7%), accidental removal (UG 9.5%; CG 9.5%), phlebitis (UG 9.5%; CG 9.5%), infiltration (CG 9.5%), and catheter breakage/leakage (UG 9.5%). The main veins used were the basilic, cephalic, and external jugular veins, and there were no significant differences (p = 0.407) between groups with respect to the successful positioning of the PICC (UG 85.7%; CG 52.4%). Although not significant, the external jugular vein was used more frequently in the CG, and the basilic vein was used more frequently in the UG. The basilic vein is the first choice for PICC insertion. In many situations, the palpation and visualization of this vein can be extremely difficult (4, 5). The external jugular vein is indicated as the site of PICC insertion in children and can allow better visualization; however, external jugular vein cannulation requires a high level of skill and experience to obtain good results (6). We appreciate the comments by Gaspar et al (1) and for the opportunity to provide additional information regarding our study. The authors have not disclosed any potential conflicts of interest.