Characterisation of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes: A Regional Hospital Study

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Methods A retrospective observational study was conducted following the approval of the Ethics Committee. Data from 2018–2022 were collected from medical records, with a focus on patient treatment and follow-up. Results A total of 72 type 1 diabetes (T1D) patients with 30 DKA presentations were identified. The mean age at DKA presentation was 11.9 +/- 3.2 years, with 42.1% having new-onset T1D. An equal number of patients presented with mild (50%) and moderate to severe DKA. Of these, 24 presentations were managed with insulin infusion, and 6 (20%) were managed with subcutaneous insulin. Following a mean ED stay of 7.93 +/- 4.8 hours, 14 patients (93.3%) were transferred to the CCU or ward, and 2 were transferred out. The mean HbA1c was 12.55 +/- 2.1%, with a mean recovery time of 10.4 hours for pH and 6.4 hours for bicarbonate. Minor complications occurred in 10% of patients (all on insulin infusion). All patients were discharged in stable condition after 2.15 +/- 1.3 days. The follow-up rate was 72.2% (13/18), with a mean Hba1c of 8.32 +/- 1.8%. Conclusion Regional hospitals witness a high frequency of children with T1D presenting with DKA as their first presentation. Targeting bicarbonate levels for acidosis correction could help facilitate an earlier transition to subcutaneous insulin and needs due consideration. This study substantiates the use of upfront subcutaneous insulin for mild to moderate DKA with good outcomes. Follow-up care remains a crucial gap that necessitates strengthening regional diabetes management teams. Type 1 Diabetes Diabetic Ketoacidosis Regional Centre Insulin Figures Figure 1 HIGHLIGHTS What is already known about this topic? In regional areas in Australia, the risk of Diabetic ketoacidosis (DKA) as the first manifestation of type 1 diabetes (T1D) is 1.5 times greater. Although the incidence of T1D has remained stable in recent years, the highest increase has been in regional areas. DKA is conventionally managed with insulin infusion, which is labor intensive and may lead to complications with prolonged use. The 2022 International society of pediatric and adolescent diabetes (ISPAD) guidelines propose subcutaneous insulin for managing mild and moderate DKA in otherwise well children, but empirical data on its application, particularly in regional areas, are limited. What does this study add? This study confirms the increased risk of DKA as the first presentation of T1D in this regional center. Most DKA patients presenting to our regional hospital are managed locally. Emphasis on bicarbonate recovery as a target for acidosis correction in the guidelines could facilitate an earlier transition to SC insulin for those initiated on an insulin infusion, potentially reducing the intensive management demand at regional centres. This study establishes the safe use of SC insulin in managing a specific subset of paediatric DKA patients. Introduction “Diabetes mellitus” is a complex metabolic disorder characterised by chronic hyperglycemia due to defects in insulin secretion, insulin action, or both. The absence of insulin production or secretion is typically referred to as type 1 diabetes (T1D) (1). The global incidence of T1D is reported to be 15 per 100,000 individuals (2), with predictive modelling indicating a rapid increase in these estimates over the next two decades (3). In 2016, the Australian Institute of Health and Welfare (AIHW) reported an annual incidence of type 1 diabetes of 10–13 cases per 100,000 people in Australia (4), which aligns with the worldwide incidence figures. While the incidence rates of T1D in Australia have remained stable between 2020 and 2021, notably, the highest rates are observed in inner regional areas (5). Children with T1D typically present with weight loss, polydipsia and polyuria (1). They may also first present in diabetic ketoacidosis (DKA), a life-threatening manifestation of insulin deficiency with features of hyperglycaemia, acidosis and ketones in blood and urine. In countries with a high incidence of T1D, greater familiarity among medical practitioners with the condition results in a lower occurrence of DKA at the time of diagnosis (6). Routine childhood illnesses and missed insulin doses also result in DKA among patients known to have T1D. DKA is usually managed with fluids and insulin infusion with frequent monitoring of acid‒base and electrolytes. Cerebral edema, a rare complication, primarily occurs in the early phase of DKA management and affects approximately 0.5% of cases (6). This complication can lead to neurological consequences (7) and has a mortality rate as high as 40% (8). Delayed diagnosis is identified as a major risk factor associated with mortality (9). Therefore, prevention and timely identification of DKA and its appropriate management are crucial. However, this process is labor intensive and can be particularly challenging in regional settings where human and infrastructural resources are often limited. In Australia, the incidence of DKA as the initial presentation of T1D is 37.7% (10) and 31.8% (11) in major cities. In contrast, regional areas in Australia present a 1.5-fold greater risk for DKA at diagnosis, as highlighted by the AIHW report (4). A recent study from a regional center in the state of Queensland reported that the average incidence of DKA at the first presentation of T1D was 48.10%, with another study reporting 50% DKA, further substantiating the increased rates observed in regional settings (12, 13). Notably, the frequency of DKA was also significantly greater during the period of COVID-19 pandemic restrictions than during prepandemic conditions (73% vs 26%; P <0.007) (14). Studies from regional Queensland noted that age, gender, rurality or indigenous status did not change the risk of DKA (12, 13). However, a recent study on diabetes-related presentations to emergency departments revealed a 68% greater risk of children presenting with DKA in regional Victoria than in metropolitan areas (15). These findings underscore the need for further research into DKA presentations in rural children and youth. There is currently no published literature characterising this life-threatening emergency in regional Victoria. Victoria ranks as the third highest state for T1D incidence according to the AIHW 2020 report. This study was undertaken as an initial step to address the need to examine DKA presentations at a regional hospital in Victoria with the aim of enhancing our understanding and improving community referral services for better childhood T1D care. Methods Ethics - This observational study was conducted with the approval of the Hospital Ethics Committee at Latrobe Regional Health (LRH), project no. 2023-47 QA. Setting - LRH is a regional health service in Victoria, Australia that caters to the needs of the Latrobe valley covering an area of 1,426 square kilometres and a population of around 78,000. Children 0-14 years contribute to approximately 20% of the population. This healthcare service is a secondary care academic institution in a rural setting. Study design and data collection - This is an observational study for which data was obtained from the medical records of all children and adolescents (aged 0-16 years) admitted to LRH over five years, from 1st Jan 2018 to 31st Dec 2022, who had T1D or DKA at their time of diagnosis (codes E1011 and E109). Basic demographic data, type of DKA, treatment details and place of treatment within the hospital was obtained. Outpatient clinic software was used to obtain follow-up details including type of insulin, duration of follow-up and Hba1c. In 2020, the hospital transitioned to a fully electronic record system, so the data collection included written charts and electronic records. The data were coded and entered into a password-protected Microsoft Excel spreadsheet in a confidential, deidentified manner by single author (SK) with access restricted solely to the investigators. No personal computers or data devices were used to collect, transfer or store data. Definitions- Patients were classified into diabetic ketosis, mild, moderate, and severe DKA groups based on the ISPAD guideline definitions (1) with the initial gas of venous or arterial or capillary measurement included. Capillary glucose as noted on the glucometer and blood ketones as noted using ketone strips were included. The study analysis focused on patients who presented with DKA. The point of pH recovery was determined as the time when the pH level exceeded 7.30 and bicarbonate recovery as the time at which bicarbonate levels surpassed 15 mmol/l by any one of venous, arterial or capillary gas measurements. Statistical analyses - Statistical analyses- Simple descriptive statistics using mean and standard deviation and proportions were used for the analysis. No tests of significance were employed. Selection bias was addressed by ensuring only those with eligible hospital codes were included. Data loss due to absence of paper charts in 20/93 screened is a potential bias (figure 1). The manuscript was prepared per the STROBE guidelines for reporting observational studies. The main aim of the study was to characterise the baseline clinical and biochemical characteristics of DKA patients. The specific objectives to be studied were defined as follows: Calculation of the mean duration for recovery of pH and bicarbonate levels. Assessment of in-hospital disposition (ward/CCU/ED), the mean duration of hospital stay and complications were noted. Follow-up data analysis. Description of the cohort of patients managed with subcutaneous insulin from the outset. Results Out of 93 records screened, data were collected from 72 children with T1D who presented to the emergency department and inpatient services between 2018 and 2022. Owing to the maintenance of paper records before 2020, charts for 20 patients could not be screened, and one patient excluded had stress hyperglycaemia. A total of 30 DKA presentations were recorded over 5 years, comprising 16 male patients and 14 female patients. Eighteen patients accounted for the 30 DKA presentations, with 5 patients experiencing multiple admissions during this period. DKA was identified as the first manifestation of T1D in 42.1% (8/19) of patients. Figure 1 illustrates the flowchart of the study flow process. Baseline clinical and biochemical characteristics: The baseline characteristics of the patients are summarised in Table 1 with continuous variables expressed as mean ± standard deviation and categorical variables as number or percentages. The mean age of patients at DKA presentation was 11.9 ± 3.2 years. According to the ISPAD guidelines, 50% of the cases were classified as mild DKA (15/30), 26.7% as moderate DKA (8/30) and 23.3% as severe DKA (7/30). At the time of presentation, the mean pH was 7.18 ± 0.09, with a mean venous bicarbonate of 12.35 ± 3.29 mmol/L. The mean venous glucose level was 28.77 ± 8.14 mmol/L, and the mean blood ketone level recorded by the glucometer was 5.5 ± 0.86 mmol/L. The mean HbA1c at DKA presentation (n=11) was 12.55 ± 2.06%. Twenty-four patients received insulin infusion for a mean duration of 10.72 ± 8.99 hours, while 6 patients (20%) were treated with subcutaneous insulin. Two patients at presentation received continuous subcutaneous insulin infusion (CSII), while the remaining patients were either on or initiated multiple daily subcutaneous insulin injections with a basal-bolus regimen. All patients belonged to the most disadvantaged category as per the IRSAD classification. Table 1. Baseline patient profile Parameter Value Total Patients with DKA 18 Patients with Multiple DKA Admissions 5 Total DKA presentations 30 Frequency of DKA presentations 2018 2019 2020 2021 2022 5 4 4 4 13 Age at DKA presentation 11.9 ± 3.2 years Age at T1D diagnosis 8.9 ± 4.4 years Gender Males Females 16 14 DKA Severity Distribution Mild DKA Moderate DKA Severe DKA 50% (15/30) 26.7% (8/30) 23.3% (7/30) Biochemical parameters at presentation pH Bicarbonate Glucose Blood Ketone HbA1c (n=11) 7.18 ± 0.09 12.58 ± 3.16 mmol/L 28.77 ± 8.14 mmol/L 5.5 ± 0.86 mmol/L 12.55 ± 2.06% Evaluation of Patient Outcomes: The results of the analysis of recovery times and other patient outcomes are summarised in Table 2 with continuous variables expressed as mean ± standard deviation and categorical variables as number or percentages. Among the 18 patients who presented, 2 were on CSII, and 16 were on multiple daily SC insulin. The same insulin delivery regime with adjusted doses was continued after DKA management. Mean recovery time for pH and bicarbonate levels. The mean duration for pH recovery was 10.36 ± 7.79 hours, whereas bicarbonate recovery occurred in 6.41 ± 5.44 hours. In all instances, bicarbonate recovery occurred earlier than pH recovery, except for two cases where gastrointestinal illness precipitated DKA. In-hospital Outcomes: Disposition, Length of stay and complications. All patients were initially managed in the Emergency Department (ED), with an average duration of ED stay of 7.93 ± 4.85 hours. Fourteen patients were subsequently transferred to the critical care unit, and another 14 were moved to the paediatric ward in the hospital. Two patients were directly transferred to a tertiary care centre from the ED after consultation with retrieval services. One patient who had recently undergone surgery for a complex heart condition was transferred from the CCU to the tertiary centre due to concerns of coagulopathy following recovery from DKA. The average length of hospital stay was 2.15 ± 1.32 days, with a mean of 3.7 days in the insulin infusion group and 1.7 days in the SC insulin group. Three patients required active intervention for complications: one patient with hyperkalaemia (potassium 6.4 mmol/L) had potassium supplementation decreased from 60 to 30 ml/L in the fluids; another patient with hypokalaemia (potassium 3.1 mmol/L) received oral potassium supplementation and hypoglycaemia, with a glucose level of 2.1 mmol/L requiring a dextrose bolus along with temporary suspension of the insulin infusion for an hour. Additionally, a third patient with hypophosphatemia was given oral phosphate supplementation. All 28 patients managed at LRH were discharged in stable condition. Posthospitalisation Follow-up: Percentage of patients with more than one year of follow-up and average follow-up duration. Thirteen out of 18 patients were followed up at the hospital clinic for a mean duration of 1.65 ± 1.62 years following their initial presentation. The mean HbA1c at the last follow-up was 8.32 ± 1.80%, with a mean total daily insulin dose of 0.96 U/kg/day. Two patients were transferred to other local services for ongoing follow-up, and one was transitioned to adult endocrine services at LRH. Additionally, two patients did not return to the outpatient clinic after their DKA was managed and were thus considered lost to follow-up. Table 2: Summary of the results of the outcome measures Outcome Measures Value Number of patients initiated on insulin Infusion 24 Number of patients initiated on subcutaneous insulin 6 (20%) Duration of insulin infusion 10.72 ± 8.99 hours Time to pH Recovery 10.67 ± 7.85 hours Time to Bicarbonate Recovery 6.79 5.5 ± 4 hours ED Stay Duration 7.93 ± 4.80 hours Transfers post-ED stay Critical Care Unit Paediatric Ward Tertiary Care Centre 14 patients 14 patients 2 patients Length of Hospital Stay Insulin Infusion Group (24) SC Insulin Group (6) 2.18 ± 1.3 days 2.3 days 1.7 days Complications Needing Intervention 3 patients Discharge Condition All 28 patients stable Follow-Up post-hospitalisation at our centre 13/18 patients Duration of Follow-Up 1.65 ± 1.62 years HbA1c at Last Follow-Up 8.32 ± 1.80% Insulin Dose at Follow-Up 0.96 U/kg/day Transfers to Other Services 3 patients (2 local, 1 adult endocrine) Loss to Follow-Up 2 patients Overview of patients managed with subcutaneous insulin from the outset. A total of 20% (6/30) of patients received subcutaneous insulin from the beginning of their treatment. The characteristics of this cohort are summarised in Table 3. Most of these patients presented with mild DKA (5/6), whereas one patient presented with severe DKA. The mean time to pH recovery was 2.67 +/- 3.1 hrs, and that to bicarbonate recovery was 2.75 ± 2.13 hrs. The mean duration of ED stay was 9.67 ± 5.9 hrs, whereas the mean in-hospital stay was 1.67 ± 1 hr. Table 3. Characteristics of children and adolescents with DKA managed with subcutaneous insulin Case Age Gender DKA Severity pH at Presentation Bicarbonate at Presentation Time to pH Recovery Time to Bicarbonate Recovery ED Stay Duration Length of Hospital Stay 1 8 F Mild 7.25 16.3 3 0 8 1 2 15 M Mild 7.29 16 1 0 4 1 3 14 M Mild 7.28 17 0 2.5 9 3 4 12 F Mild 7.202 13 4 4 21 (delay due to bed shortage) 1 5 11 F Mild 7.3 14.3 0 1 7 3 6 13 F Severe 7.08 11 8 6 9 1 Discussion T1D is a chronic condition that places a significant burden on both families and the health care system. When a child is diagnosed with DKA, initial management is particularly labour intensive and requires intravenous insulin infusion, hourly glucose and ketone checks and frequent venous gas analyses to monitor the associated acidosis. To our knowledge, this study represents the first review of this life-threatening emergency from a regional perspective in Victoria. We observed a high incidence of DKA among newly diagnosed T1D patients (42.1%). This figure exceeds the incidences reported in previous studies from urban Australia, which reported rates of 31.8% and 37.7% ( 9 , 10 ). A more recent publication by the Australian Data Network (ADDN) examining a large cohort reported that 33.2% of patients presented initially with DKA ( 17 ). In contrast, international data from a large multicentre study involving centres from developed countries across 3 continents revealed a lower rate of 29.9% ( 18 ). This presents a notable contrast to figures in Australia, particularly from regional Queensland figures of 48.1% and 50% ( 12 , 13 ). While our study revealed a lower DKA incidence than in regional Queensland, it aligns with the broader trend of increased rates of DKA as the first presentation of T1D in regional centres across Australia. This may be attributed to delayed referrals and a lower awareness of the condition among the regional population and the local medical community. Notably, increased education for health professionals led to a significant reduction in incidence, decreasing from 54.9–25%, following an intervention, as noted in a study from regional Queensland ( 12 ). Moreover, socioeconomic indices classify many regional areas as disadvantaged. A recent study analysed 10 years of data (2008–2018) on DKA presentations via an ED database in Victoria. This study revealed a 68% increase in DKA presentations in rural EDs compared with metropolitan areas, despite an overall decline in DKA presentations across EDs during this period ( 15 ). Data from the ADDN study also indicated that individuals residing in lower SES postcodes were significantly associated with higher Hba1c levels at follow-up ( 17 ). According to the IRSAD, the entire Latrobe valley, which is serviced by our hospital, is classified within the most disadvantaged category in Victoria ( 19 ). This social determinant could also contribute to the higher incidence of DKA in this study. Most of the patients were treated at our regional hospital, with only 6.7% (2 out of 30) requiring transfer to a referral centre. These data align with those of a Victorian ED-based study, which revealed that 10% of the patients were transferred out during 2017–2018 ( 15 ). This highlights a crucial opportunity, as strengthening diabetes care in regional centres could lead to improved emergency management locally and better utilisation of the existing infrastructure in regional hospitals. The subcutaneous insulin regimen can effectively manage paediatric DKA ( 20 ), particularly in regional hospitals. However, the medical team must make informed decisions regarding its applicability and patient selection. The new ISPAD guidelines, published in 2022, support the use of subcutaneous insulin for treating uncomplicated mild to moderate DKA ( 21 ). In our study, 20% of the patients were managed with subcutaneous insulin, including one patient with severe DKA, and favourable outcomes were achieved. This evidence may encourage regional hospitals to consider SC insulin therapy for DKA, potentially reducing complications and the overall burden of care. Further research is necessary to validate these findings and to shift the perspective of the health care professionals involved, ultimately influencing their practices and the local guidelines. Notably, bicarbonate recovery in this study occurred almost 4 hours earlier than did pH recovery. While most local Australian protocols mention both criteria for transition to SC therapy, they lack clarity on whether it should be pH “or” bicarbonate or both pH “and” bicarbonate recovery. This ambiguity leaves the decision to transition to SC therapy dependent on the clinical judgement of the treating paediatrician; hence, more clarity on the same would be beneficial. In this study, the average length of ED stay was 7.93 hours, and the average length of in-hospital stay was 2.18 days. Estimates from the US indicate that the average cost of hospital admission for DKA is 27000 USD, whereas equivalent data from Australia are lacking ( 19 , 22 ). Thus, ensuring that protocols prioritise patient safety while minimising hospital stays can help decrease the economic burden on the healthcare system. In our study, 18 patients accounted for 30 episodes of DKA, with 5 of these patients experiencing recurrent presentations. The primary contributing factors identified from medical records include a lack of adherence to sick day management protocols, mental health concerns and various social factors. This underscores the importance of a multidisciplinary allied health team in regional centres providing care for T1D patients. However, a comprehensive, in-depth analysis of these factors was not feasible because of the observational nature of this study. The importance of ensuring a smooth transition of care from an inpatient setting to outpatient follow-up for all individuals diagnosed with T1D presenting with DKA cannot be overstated, as T1D is a chronic condition. Despite its significance, the current literature indicates a lack of data on the transitions from regional centres in Australia. In our study, 72.2% (13/18) of patients were followed up, with 3 who transitioned to another local service for ongoing diabetes care and 2 who were lost to follow-up. Further investigation into the reasons for loss to follow-up is necessary to gain insights and address any obstacles in the future. Research suggests that presenting with DKA at diagnosis, especially severe DKA, is associated with higher HbA1c at follow-up ( 16 , 17 ). Although our incidence of DKA presentation was higher, the percentage of those with severe DKA (23.3%) was lower than the 29.3% reported in the ADDN study ( 17 ). A more structured and longer follow-up analysis will provide more insight into the glycaemic control of children in our region. Our study has a few limitations. This was a retrospective study, and we were unable to review the records of all the patients. Additionally, our research is based on data from a single regional centre in Victoria, which may not represent all regional centres across Australia or the world. The number of patients receiving subcutaneous insulin was limited, making it difficult to draw out significant differences compared with insulin infusion. Importantly, our study concluded in December 2022, shortly after the ISPAD guidelines, which endorsed the use of subcutaneous insulin in DKA, were published in early 2022. Data from 2023 onwards will provide further clarity on this topic. Conclusion This study was designed to address the knowledge gap regarding the incidence of DKA in regional Victoria. A substantial portion of 42.1% of the new paediatric T1D patients presented with DKA to our regional centre in Australia. Notably, over 28 out of 30 (93.3%) of these patients were managed locally, and one-fifth were treated with subcutaneous insulin, achieving favourable outcomes in line with the ISPAD guideline recommendations published in 2022. The findings from this study provide a better understanding of the biochemical abnormalities and intensive management required for children with DKA during hospitalisation. We hope that this study will increase awareness in the region, potentially leading to early diagnoses and a reduction in the period prevalence of DKA associated with new-onset T1D. Additionally, we advocate for a greater emphasis on using SC insulin in DKA management. Furthermore, we call for more research on DKA in regional Australia to understand the factors contributing to the increased risk of DKA in these areas and to explore the social factors influencing adherence to insulin therapy. Strengthening health support offered by diabetes teams regionally is crucial for improving follow-up and achieving better health outcomes for individuals affected by this prevalent noncommunicable disease. Abbreviations DKA- Diabetic ketoacidosis T1D- Type 1 Diabetes ED- Emergency Department CCU- Critical Care Unit LRH- Latrobe Regional Health ISPAD- International Society of Paediatric and Adolescent Diabetes SC- Subcutaneous AIHW- Australian Institute of Health and Welfare IRSAD- Index of relative socioeconomic advantage and disadvantage Declarations Ethics approval and consent to participate- This study adhered to the Declaration of Helsinki . The approval of the Hospital Ethics Committee at Latrobe Regional Health (project no. 2023-47 QA), Traralgon, Victoria, Australia was obtained. A waiver of consent was obtained owing to the study being an audit on practice. Consent for publication - Not applicable. Availability of data and materials - Included Competing Interests - nil Funding- nil Authors' contributions- SK- Data collection, analyses, manuscript writing and editing AK- Analyses, manuscript writing and editing LB- Manuscript writing and editing Acknowledgements: The authors would like to acknowledge the health care workers involved in managing all these patients at Latrobe Regional Health. References Libman I, Haynes A, Lyons S, Pradeep P, Rwagasor E, Tung JY, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatric Diabetes [Internet]. 2022 Dec [cited 2023 Jan 30];23(8):1160–74. Mobasseri M, Shirmohammadi M, Amiri T, Vahed N, Hosseini Fard H, Ghojazadeh M. Prevalence and Incidence of type 1 diabetes in the world: a systematic review and meta-analysis. Health Promotion Perspectives [Internet]. 2020 Mar 30;10(2):98–115. 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Supplementary Files DKALRHDataSheetBMCMarch24.xlsx Cite Share Download PDF Status: Published Journal Publication published 07 Jun, 2025 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 14 Apr, 2025 Reviews received at journal 13 Apr, 2025 Reviews received at journal 12 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers agreed at journal 01 Apr, 2025 Reviewers invited by journal 29 Mar, 2025 Submission checks completed at journal 25 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5928922","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435652936,"identity":"7f24d336-cae4-4f40-be29-e90f233a2978","order_by":0,"name":"Sophy Korula","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYHACNiBOAGLmBoYPYAEeqCBhLYwNjDNI1sLMQ4wW+fbeY495GNLkzGckNn62zbHJ4+8/e4DhQ9lhnFoMzpxLN+ZhyDGWuZHYLJ27La1Y4kZeAuOMc3i0SOSYSfMwVCTOkEhsAGo5nNhwg8eAmbcNtxb5GQgtzb8tgVrmnz9jwPwXjxaGG2AtOSAtbdKMQC0bDuQYMDPi0QL0S5rkHIM0Ywmeh22WvdvSEjfeyDE42HMuHbfDgCEm8aYiWU6CPfnwjZ/bbBLnnT9j+OBHmTVuhwFjgYnHAE3sAB71YC2MP/CrGAWjYBSMgpEOAM2mVHNynGIxAAAAAElFTkSuQmCC","orcid":"","institution":"Latrobe Regional Hospital","correspondingAuthor":true,"prefix":"","firstName":"Sophy","middleName":"","lastName":"Korula","suffix":""},{"id":435652937,"identity":"ca5883ad-78e9-40a0-800f-207f1b673edd","order_by":1,"name":"Sheikh Arif Maqbool Kozgar","email":"","orcid":"","institution":"Latrobe Regional Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sheikh","middleName":"Arif Maqbool","lastName":"Kozgar","suffix":""},{"id":435652938,"identity":"6d3bccd5-5459-46fc-8921-13709658990e","order_by":2,"name":"Lloyd Bwanaisa","email":"","orcid":"","institution":"Latrobe Regional Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lloyd","middleName":"","lastName":"Bwanaisa","suffix":""}],"badges":[],"createdAt":"2025-01-30 09:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5928922/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5928922/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-025-05824-0","type":"published","date":"2025-06-07T15:57:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79678375,"identity":"935ee16b-fb06-433a-98d7-b28a9817e598","added_by":"auto","created_at":"2025-04-01 12:28:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53773,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow diagram\u003c/p\u003e\n\u003cp\u003e# Total of 11 - 1 for mental health concerns, 4 for re-education due to poor control, 2 in preterm labour, 2 with hypoglycaemia, 2 for evaluation of musculoskeletal pain\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5928922/v1/9207dbb3147eee4f19c2cecb.jpg"},{"id":84242641,"identity":"2181fd93-73bf-47d4-b1b8-a88d5d216904","added_by":"auto","created_at":"2025-06-09 16:10:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":802271,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5928922/v1/51ad9121-fc83-465d-824b-ecaf49563225.pdf"},{"id":79679413,"identity":"b30b3061-07d2-4126-9797-443761a23730","added_by":"auto","created_at":"2025-04-01 12:36:24","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":24853,"visible":true,"origin":"","legend":"","description":"","filename":"DKALRHDataSheetBMCMarch24.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-5928922/v1/edcff700b33e434f304a3f69.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eCharacterisation of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes: A Regional Hospital Study\u003c/p\u003e","fulltext":[{"header":"HIGHLIGHTS","content":"\u003cp\u003e\u003cstrong\u003eWhat is already known about this topic?\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eIn regional areas in Australia, the risk of Diabetic ketoacidosis (DKA) as the first manifestation of type 1 diabetes (T1D) is 1.5 times greater.\u003c/li\u003e\n \u003cli\u003eAlthough the incidence of T1D has remained stable in recent years, the highest increase has been in regional areas.\u003c/li\u003e\n \u003cli\u003eDKA is conventionally managed with insulin infusion, which is labor intensive and may lead to complications with prolonged use.\u003c/li\u003e\n \u003cli\u003eThe 2022 International society of pediatric and adolescent diabetes (ISPAD) guidelines propose subcutaneous insulin for managing mild and moderate DKA in otherwise well children, but empirical data on its application, particularly in regional areas, are limited.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eWhat does this study add?\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eThis study confirms the increased risk of DKA as the first presentation of T1D in this regional center.\u003c/li\u003e\n \u003cli\u003eMost DKA patients presenting to our regional hospital are managed locally.\u003c/li\u003e\n \u003cli\u003eEmphasis on bicarbonate recovery as a target for acidosis correction in the guidelines could facilitate an earlier transition to SC insulin for those initiated on an insulin infusion, potentially reducing the intensive management demand at regional centres.\u003c/li\u003e\n \u003cli\u003eThis study establishes the safe use of SC insulin in managing a specific subset of paediatric DKA patients.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Introduction","content":"\u003cp\u003e\u0026nbsp;\u0026ldquo;Diabetes mellitus\u0026rdquo; is a complex metabolic disorder characterised by chronic hyperglycemia due to defects in insulin secretion, insulin action, or both. The absence of insulin production or secretion is typically referred to as type 1 diabetes (T1D) (1). The global incidence of T1D is reported to be 15 per 100,000 individuals (2), with predictive modelling indicating a rapid increase in these estimates over the next two decades (3). In 2016, the Australian Institute of Health and Welfare (AIHW) reported an annual incidence of type 1 diabetes of 10\u0026ndash;13 cases per 100,000 people in Australia (4), which aligns with the worldwide incidence figures. While the incidence rates of T1D in Australia have remained stable between 2020 and 2021, notably, the highest rates are observed in inner regional areas (5).\u003c/p\u003e\n\u003cp\u003eChildren with T1D typically present with weight loss, polydipsia and polyuria (1). They may also first present in diabetic ketoacidosis (DKA), a life-threatening manifestation of insulin deficiency with features of hyperglycaemia, acidosis and ketones in blood and urine. In countries with a high incidence of T1D, greater familiarity among medical practitioners with the condition results in a lower occurrence of DKA at the time of diagnosis (6). Routine childhood illnesses and missed insulin doses also result in DKA among patients known to have T1D. DKA is usually managed with fluids and insulin infusion with frequent monitoring of acid‒base and electrolytes. Cerebral edema, a rare complication, primarily occurs in the early phase of DKA management and affects approximately 0.5% of cases (6). This complication can lead to neurological consequences (7) and has a mortality rate as high as 40% (8). Delayed diagnosis is identified as a major risk factor associated with mortality (9). Therefore, prevention and timely identification of DKA and its appropriate management are crucial. However, this process is labor intensive and can be particularly challenging in regional settings where human and infrastructural resources are often limited.\u003c/p\u003e\n\u003cp\u003eIn Australia, the incidence of DKA as the initial presentation of T1D is 37.7% (10) and 31.8% (11) in major cities. In contrast, regional areas in Australia present a 1.5-fold greater risk for DKA at diagnosis, as highlighted by the AIHW report (4). A recent study from a regional center in the state of Queensland reported that the average incidence of DKA at the first presentation of T1D was 48.10%, with another study reporting 50% DKA, further substantiating the increased rates observed in regional settings (12, 13). Notably, the frequency of DKA was also significantly greater during the period of COVID-19 pandemic restrictions than during prepandemic conditions (73% vs 26%; \u003cem\u003eP\u003c/em\u003e \u0026lt;0.007) (14). Studies from regional Queensland noted that age, gender, rurality or indigenous status did not change the risk of DKA (12, 13). However, a recent study on diabetes-related presentations to emergency departments revealed a 68% greater risk of children presenting with DKA in regional Victoria than in metropolitan areas (15). These findings underscore the need for further research into DKA presentations in rural children and youth.\u003c/p\u003e\n\u003cp\u003eThere is currently no published literature characterising this life-threatening emergency in regional Victoria. Victoria ranks as the third highest state for T1D incidence according to the AIHW 2020 report. This study was undertaken as an initial step to address the need to examine DKA presentations at a regional hospital in Victoria with the aim of enhancing our understanding and improving community referral services for better childhood T1D care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eEthics\u0026nbsp;\u003c/strong\u003e- This observational study was conducted with the approval of the Hospital Ethics Committee at Latrobe Regional Health (LRH), project no. 2023-47 QA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e- LRH is a regional health service in Victoria, Australia that caters to the needs of the Latrobe valley covering an area of 1,426 square kilometres and a population of around 78,000. Children 0-14 years contribute to approximately 20% of the population. This healthcare service is a secondary care academic institution in a rural setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and data collection\u003c/strong\u003e- This is an observational study for which data was obtained from the medical records of all children and adolescents (aged 0-16 years) admitted to LRH over five years, from 1st Jan 2018 to 31st Dec 2022, who had T1D or DKA at their time of diagnosis (codes E1011 and E109). Basic demographic data, type of DKA, treatment details and place of treatment within the hospital was obtained. Outpatient clinic software was used to obtain follow-up details including type of insulin, duration of follow-up and Hba1c. \u0026nbsp;In 2020, the hospital transitioned to a fully electronic record system, so the data collection included written charts and electronic records. The data were coded and entered into a password-protected Microsoft Excel spreadsheet in a confidential, deidentified manner by single author (SK) with access restricted solely to the investigators. No personal computers or data devices were used to collect, transfer or store data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDefinitions-\u003c/strong\u003e Patients were classified into diabetic ketosis, mild, moderate, and severe DKA groups based on the ISPAD guideline definitions (1) with the initial gas of venous or arterial or capillary measurement included. Capillary glucose as noted on the glucometer and blood ketones as noted using ketone strips were included. The study analysis focused on patients who presented with DKA. The point of pH recovery was determined as the time when the pH level exceeded 7.30 and bicarbonate recovery as the time at which bicarbonate levels surpassed 15 mmol/l by any one of venous, arterial or capillary gas measurements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analyses\u003c/strong\u003e- Statistical analyses- Simple descriptive statistics using mean and standard deviation and proportions were used for the analysis. No tests of significance were employed. Selection bias was addressed by ensuring only those with eligible hospital codes were included. Data loss due to absence of paper charts in 20/93 screened is a potential bias (figure 1).\u003c/p\u003e\n\u003cp\u003eThe manuscript was prepared per the STROBE guidelines for reporting observational studies. The main aim of the study was to characterise the baseline clinical and biochemical characteristics of DKA patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe specific objectives to be studied were defined as follows:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eCalculation of the mean duration for recovery of pH and bicarbonate levels.\u003c/li\u003e\n \u003cli\u003eAssessment of in-hospital disposition (ward/CCU/ED), the mean duration of hospital stay and complications were noted.\u003c/li\u003e\n \u003cli\u003eFollow-up data analysis.\u003c/li\u003e\n \u003cli\u003eDescription of the cohort of patients managed with subcutaneous insulin from the outset.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Results","content":"\u003cp\u003eOut of 93 records screened, data were collected from 72 children with T1D who presented to the emergency department and inpatient services between 2018 and 2022. Owing to the maintenance of paper records before 2020, charts for 20 patients could not be screened, and one patient excluded had stress hyperglycaemia. A total of 30 DKA presentations were recorded over 5 years, comprising 16 male patients and 14 female patients. Eighteen patients accounted for the 30 DKA presentations, with 5 patients experiencing multiple admissions during this period. DKA was identified as the first manifestation of T1D in 42.1% (8/19) of patients. Figure 1 illustrates the flowchart of the study flow process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline clinical and biochemical characteristics:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe baseline characteristics of the patients are summarised in Table 1 with continuous variables expressed as mean \u0026plusmn; standard deviation and categorical variables as number or percentages. The mean age of patients at DKA presentation was 11.9 \u0026plusmn; 3.2 years. According to the ISPAD guidelines, 50% of the cases were classified as mild DKA (15/30), 26.7% as moderate DKA (8/30) and 23.3% as severe DKA (7/30). At the time of presentation, the mean pH was 7.18 \u0026plusmn; 0.09, with a mean venous bicarbonate of 12.35 \u0026plusmn; 3.29 mmol/L. The mean venous glucose level was 28.77 \u0026plusmn; 8.14 mmol/L, and the mean blood ketone level recorded by the glucometer was 5.5 \u0026plusmn; 0.86 mmol/L. The mean HbA1c at DKA presentation (n=11) was 12.55 \u0026plusmn; 2.06%. Twenty-four patients received insulin infusion for a mean duration of 10.72 \u0026plusmn; 8.99 hours, while 6 patients (20%) were treated with subcutaneous insulin. Two patients at presentation received continuous subcutaneous insulin infusion (CSII), while the remaining patients were either on or initiated multiple daily subcutaneous insulin injections with a basal-bolus regimen. All patients belonged to the most disadvantaged category as per the IRSAD classification. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Baseline patient profile\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal Patients with DKA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePatients with Multiple DKA Admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal DKA presentations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFrequency of DKA presentations\u003c/p\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge at DKA presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.9 \u0026plusmn; 3.2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge at T1D diagnosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.9 \u0026plusmn; 4.4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDKA Severity Distribution\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mild DKA\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Moderate DKA\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Severe DKA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e50% (15/30)\u003c/p\u003e\n \u003cp\u003e26.7% (8/30)\u003c/p\u003e\n \u003cp\u003e23.3% (7/30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBiochemical parameters at presentation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; pH\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Bicarbonate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Glucose\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Blood Ketone\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; HbA1c (n=11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.18 \u0026plusmn; 0.09\u003c/p\u003e\n \u003cp\u003e12.58 \u0026plusmn; 3.16 mmol/L\u003c/p\u003e\n \u003cp\u003e28.77 \u0026plusmn; 8.14 mmol/L\u003c/p\u003e\n \u003cp\u003e5.5 \u0026plusmn; 0.86 mmol/L\u003c/p\u003e\n \u003cp\u003e12.55 \u0026plusmn; 2.06%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation of Patient Outcomes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the analysis of recovery times and other patient outcomes are summarised in Table 2 with continuous variables expressed as mean \u0026plusmn; standard deviation and categorical variables as number or percentages. Among the 18 patients who presented, 2 were on CSII, and 16 were on multiple daily SC insulin. The same insulin delivery regime with adjusted doses was continued after DKA management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean recovery time for pH and bicarbonate levels.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean duration for pH recovery was 10.36 \u0026plusmn; 7.79 hours, whereas bicarbonate recovery occurred in 6.41 \u0026plusmn; 5.44 hours. In all instances, bicarbonate recovery occurred earlier than pH recovery, except for two cases where gastrointestinal illness precipitated DKA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn-hospital Outcomes: Disposition, Length of stay and complications.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were initially managed in the Emergency Department (ED), with an average duration of ED stay of 7.93 \u0026plusmn; 4.85 hours. Fourteen patients were subsequently transferred to the critical care unit, and another 14 were moved to the paediatric ward in the hospital. Two patients were directly transferred to a tertiary care centre from the ED after consultation with retrieval services. One patient who had recently undergone surgery for a complex heart condition was transferred from the CCU to the tertiary centre due to concerns of coagulopathy following recovery from DKA. The average length of hospital stay was 2.15 \u0026plusmn; 1.32 days, with a mean of 3.7 days in the insulin infusion group and 1.7 days in the SC insulin group. Three patients required active intervention for complications: one patient with hyperkalaemia (potassium 6.4 mmol/L) had potassium supplementation decreased from 60 to 30 ml/L in the fluids; another patient with hypokalaemia (potassium 3.1 mmol/L) received oral potassium supplementation and hypoglycaemia, with a glucose level of 2.1 mmol/L requiring a dextrose bolus along with temporary suspension of the insulin infusion for an hour. Additionally, a third patient with hypophosphatemia was given oral phosphate supplementation. All 28 patients managed at LRH were discharged in stable condition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePosthospitalisation Follow-up: Percentage of patients with more than one year of follow-up and average follow-up duration.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirteen out of 18 patients were followed up at the hospital clinic for a mean duration of 1.65 \u0026plusmn; 1.62 years following their initial presentation. The mean HbA1c at the last follow-up was 8.32 \u0026plusmn; 1.80%, with a mean total daily insulin dose of 0.96 U/kg/day. Two patients were transferred to other local services for ongoing follow-up, and one was transitioned to adult endocrine services at LRH. Additionally, two patients did not return to the outpatient clinic after their DKA was managed and were thus considered lost to follow-up.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Summary of the results of the outcome measures\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Measures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of patients initiated on insulin Infusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of patients initiated on subcutaneous insulin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDuration of insulin infusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.72 \u0026plusmn; 8.99 hours\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime to pH Recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.67 \u0026plusmn; 7.85 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime to Bicarbonate Recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.79 5.5 \u0026plusmn; 4 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;ED Stay Duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.93 \u0026plusmn; 4.80 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTransfers post-ED stay\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Critical Care Unit\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Paediatric Ward\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Tertiary Care Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 patients\u003c/p\u003e\n \u003cp\u003e14 patients\u003c/p\u003e\n \u003cp\u003e2 patients \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLength of Hospital Stay\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Insulin Infusion Group (24)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;SC Insulin Group (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.18 \u0026plusmn; 1.3 days\u003c/p\u003e\n \u003cp\u003e2.3 days\u003c/p\u003e\n \u003cp\u003e1.7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComplications Needing Intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDischarge Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAll 28 patients stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-Up post-hospitalisation at our centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13/18 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDuration of Follow-Up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.65 \u0026plusmn; 1.62 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHbA1c at Last Follow-Up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.32 \u0026plusmn; 1.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInsulin Dose at Follow-Up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.96 U/kg/day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTransfers to Other Services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;3 patients (2 local, 1 adult endocrine)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLoss to Follow-Up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eOverview of patients managed with subcutaneous insulin from the outset.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 20% (6/30) of patients received subcutaneous insulin from the beginning of their treatment. The characteristics of this cohort are summarised in Table 3. Most of these patients presented with mild DKA (5/6), whereas one patient presented with severe DKA. The mean time to pH recovery was 2.67 +/- 3.1 hrs, and that to bicarbonate recovery was 2.75 \u0026plusmn; 2.13 hrs. The mean duration of ED stay was 9.67 \u0026plusmn; 5.9 hrs, whereas the mean in-hospital stay was 1.67 \u0026nbsp;\u0026plusmn; 1 hr.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Characteristics of children and adolescents with DKA managed with subcutaneous insulin\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"833\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eDKA Severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003epH at Presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBicarbonate at Presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eTime to pH Recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eTime to Bicarbonate Recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eED Stay Duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eLength of Hospital Stay\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e21 (delay due to bed shortage)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eT1D is a chronic condition that places a significant burden on both families and the health care system. When a child is diagnosed with DKA, initial management is particularly labour intensive and requires intravenous insulin infusion, hourly glucose and ketone checks and frequent venous gas analyses to monitor the associated acidosis.\u003c/p\u003e \u003cp\u003eTo our knowledge, this study represents the first review of this life-threatening emergency from a regional perspective in Victoria. We observed a high incidence of DKA among newly diagnosed T1D patients (42.1%). This figure exceeds the incidences reported in previous studies from urban Australia, which reported rates of 31.8% and 37.7% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A more recent publication by the Australian Data Network (ADDN) examining a large cohort reported that 33.2% of patients presented initially with DKA (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In contrast, international data from a large multicentre study involving centres from developed countries across 3 continents revealed a lower rate of 29.9% (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This presents a notable contrast to figures in Australia, particularly from regional Queensland figures of 48.1% and 50% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). While our study revealed a lower DKA incidence than in regional Queensland, it aligns with the broader trend of increased rates of DKA as the first presentation of T1D in regional centres across Australia. This may be attributed to delayed referrals and a lower awareness of the condition among the regional population and the local medical community. Notably, increased education for health professionals led to a significant reduction in incidence, decreasing from 54.9\u0026ndash;25%, following an intervention, as noted in a study from regional Queensland (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Moreover, socioeconomic indices classify many regional areas as disadvantaged. A recent study analysed 10 years of data (2008\u0026ndash;2018) on DKA presentations via an ED database in Victoria. This study revealed a 68% increase in DKA presentations in rural EDs compared with metropolitan areas, despite an overall decline in DKA presentations across EDs during this period (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Data from the ADDN study also indicated that individuals residing in lower SES postcodes were significantly associated with higher Hba1c levels at follow-up (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). According to the IRSAD, the entire Latrobe valley, which is serviced by our hospital, is classified within the most disadvantaged category in Victoria (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This social determinant could also contribute to the higher incidence of DKA in this study.\u003c/p\u003e \u003cp\u003eMost of the patients were treated at our regional hospital, with only 6.7% (2 out of 30) requiring transfer to a referral centre. These data align with those of a Victorian ED-based study, which revealed that 10% of the patients were transferred out during 2017\u0026ndash;2018 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This highlights a crucial opportunity, as strengthening diabetes care in regional centres could lead to improved emergency management locally and better utilisation of the existing infrastructure in regional hospitals.\u003c/p\u003e \u003cp\u003eThe subcutaneous insulin regimen can effectively manage paediatric DKA (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), particularly in regional hospitals. However, the medical team must make informed decisions regarding its applicability and patient selection. The new ISPAD guidelines, published in 2022, support the use of subcutaneous insulin for treating uncomplicated mild to moderate DKA (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In our study, 20% of the patients were managed with subcutaneous insulin, including one patient with severe DKA, and favourable outcomes were achieved. This evidence may encourage regional hospitals to consider SC insulin therapy for DKA, potentially reducing complications and the overall burden of care. Further research is necessary to validate these findings and to shift the perspective of the health care professionals involved, ultimately influencing their practices and the local guidelines. Notably, bicarbonate recovery in this study occurred almost 4 hours earlier than did pH recovery. While most local Australian protocols mention both criteria for transition to SC therapy, they lack clarity on whether it should be pH \u0026ldquo;or\u0026rdquo; bicarbonate or both pH \u0026ldquo;and\u0026rdquo; bicarbonate recovery. This ambiguity leaves the decision to transition to SC therapy dependent on the clinical judgement of the treating paediatrician; hence, more clarity on the same would be beneficial.\u003c/p\u003e \u003cp\u003eIn this study, the average length of ED stay was 7.93 hours, and the average length of in-hospital stay was 2.18 days. Estimates from the US indicate that the average cost of hospital admission for DKA is 27000 USD, whereas equivalent data from Australia are lacking (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Thus, ensuring that protocols prioritise patient safety while minimising hospital stays can help decrease the economic burden on the healthcare system.\u003c/p\u003e \u003cp\u003eIn our study, 18 patients accounted for 30 episodes of DKA, with 5 of these patients experiencing recurrent presentations. The primary contributing factors identified from medical records include a lack of adherence to sick day management protocols, mental health concerns and various social factors. This underscores the importance of a multidisciplinary allied health team in regional centres providing care for T1D patients. However, a comprehensive, in-depth analysis of these factors was not feasible because of the observational nature of this study.\u003c/p\u003e \u003cp\u003eThe importance of ensuring a smooth transition of care from an inpatient setting to outpatient follow-up for all individuals diagnosed with T1D presenting with DKA cannot be overstated, as T1D is a chronic condition. Despite its significance, the current literature indicates a lack of data on the transitions from regional centres in Australia. In our study, 72.2% (13/18) of patients were followed up, with 3 who transitioned to another local service for ongoing diabetes care and 2 who were lost to follow-up. Further investigation into the reasons for loss to follow-up is necessary to gain insights and address any obstacles in the future. Research suggests that presenting with DKA at diagnosis, especially severe DKA, is associated with higher HbA1c at follow-up (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Although our incidence of DKA presentation was higher, the percentage of those with severe DKA (23.3%) was lower than the 29.3% reported in the ADDN study (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A more structured and longer follow-up analysis will provide more insight into the glycaemic control of children in our region.\u003c/p\u003e \u003cp\u003eOur study has a few limitations. This was a retrospective study, and we were unable to review the records of all the patients. Additionally, our research is based on data from a single regional centre in Victoria, which may not represent all regional centres across Australia or the world. The number of patients receiving subcutaneous insulin was limited, making it difficult to draw out significant differences compared with insulin infusion. Importantly, our study concluded in December 2022, shortly after the ISPAD guidelines, which endorsed the use of subcutaneous insulin in DKA, were published in early 2022. Data from 2023 onwards will provide further clarity on this topic.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study was designed to address the knowledge gap regarding the incidence of DKA in regional Victoria. A substantial portion of 42.1% of the new paediatric T1D patients presented with DKA to our regional centre in Australia. Notably, over 28 out of 30 (93.3%) of these patients were managed locally, and one-fifth were treated with subcutaneous insulin, achieving favourable outcomes in line with the ISPAD guideline recommendations published in 2022. The findings from this study provide a better understanding of the biochemical abnormalities and intensive management required for children with DKA during hospitalisation. We hope that this study will increase awareness in the region, potentially leading to early diagnoses and a reduction in the period prevalence of DKA associated with new-onset T1D. Additionally, we advocate for a greater emphasis on using SC insulin in DKA management. Furthermore, we call for more research on DKA in regional Australia to understand the factors contributing to the increased risk of DKA in these areas and to explore the social factors influencing adherence to insulin therapy. Strengthening health support offered by diabetes teams regionally is crucial for improving follow-up and achieving better health outcomes for individuals affected by this prevalent noncommunicable disease.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDKA- Diabetic ketoacidosis\u003c/p\u003e\n\u003cp\u003eT1D- Type 1 Diabetes\u003c/p\u003e\n\u003cp\u003eED- Emergency Department\u003c/p\u003e\n\u003cp\u003eCCU- Critical Care Unit\u003c/p\u003e\n\u003cp\u003eLRH- Latrobe Regional Health\u003c/p\u003e\n\u003cp\u003eISPAD- International Society of Paediatric and Adolescent Diabetes\u003c/p\u003e\n\u003cp\u003eSC- Subcutaneous\u003c/p\u003e\n\u003cp\u003eAIHW- Australian Institute of Health and Welfare\u003c/p\u003e\n\u003cp\u003eIRSAD- Index of relative socioeconomic advantage and disadvantage\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate-\u0026nbsp;\u003c/strong\u003eThis study adhered to the Declaration of Helsinki\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eThe approval of the Hospital Ethics Committee at Latrobe Regional Health (project no. 2023-47 QA), Traralgon, Victoria, Australia was obtained. A waiver of consent was obtained owing to the study being an audit on practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e- Not applicable.\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e- Included\u003cbr\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e- nil\u003cbr\u003e\u003cstrong\u003eFunding-\u003c/strong\u003e nil \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cbr\u003e\u003cstrong\u003eAuthors\u0026apos; contributions-\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSK- Data collection, analyses, manuscript writing and editing\u003c/p\u003e\n\u003cp\u003eAK- Analyses, manuscript writing and editing\u003c/p\u003e\n\u003cp\u003eLB- Manuscript writing and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to acknowledge the health care workers involved in managing all these patients at Latrobe Regional Health.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLibman I, Haynes A, Lyons S, Pradeep P, Rwagasor E, Tung JY, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatric Diabetes [Internet]. 2022 Dec [cited 2023 Jan 30];23(8):1160\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eMobasseri M, Shirmohammadi M, Amiri T, Vahed N, Hosseini Fard H, Ghojazadeh M. Prevalence and Incidence of type 1 diabetes in the world: a systematic review and meta-analysis. Health Promotion Perspectives [Internet]. 2020 Mar 30;10(2):98\u0026ndash;115.\u003c/li\u003e\n\u003cli\u003eGregory GA, Robinson TIG, Linklater SE, Wang F, Colagiuri S, Beaufort C de, et al. Global incidence, prevalence, and Mortality of Type 1 Diabetes in 2021 with Projection to 2040: a Modelling Study. The Lancet Diabetes \u0026amp; Endocrinology. 2022 Oct 1;10(10):741\u0026ndash;60\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare; 2016. Diabetic ketoacidosis (DKA) among children and young people with type 1 diabetes.\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare; 2020. Prevalence of type 1 Diabetes.\u003c/li\u003e\n\u003cli\u003eWolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009;10(Suppl. 12):118-33.\u003c/li\u003e\n\u003cli\u003eCameron FJ, Scratch SE, Nadebaum C, Northam EA, Koves I, Jennings J, et al. Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children. Diabetes care. 2014;37(6):1554-62.\u003c/li\u003e\n\u003cli\u003ePatel A, Singh D, Bhatt P, Thakkar B, Akingbola OA, Srivastav SK. Incidence, Trends, and Outcomes of Cerebral Edema Among Children With Diabetic Ketoacidosis in the United States. Clin Pediatr (Phila). 2016;55(10):943-51.\u003c/li\u003e\n\u003cli\u003ePoovazhagi V. Risk factors for mortality in children with diabetic keto acidosis from developing countries. World J Diabetes. 2014 Dec 15;5(6):932-8.\u003c/li\u003e\n\u003cli\u003eClaessen FM, Donaghue K, Craig M. Consistently high incidence of diabetic ketoacidosis in children with newly diagnosed type 1 diabetes. Med J Aust. 2012;197(4):216.\u003c/li\u003e\n\u003cli\u003eWillis CM, Batch JA, Harris M. Consistently high incidence of diabetic ketoacidosis in children with newly diagnosed type 1 diabetes. Med J Aust. 2013;199(4):241-2.\u003c/li\u003e\n\u003cli\u003ePatwardhan R, Gorton S, Vangaveti VN, Yates J. Diabetic ketoacidosis incidence in children at first presentation of type 1 diabetes at an Australian regional hospital: The effect of health professional education. Pediatric Diabetes. 2018 Mar 24;19(5):993\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eCousen S, Hiskens M, Signal D, Vangaveti V, Hariharan G. Incidence and presenting features of paediatric type 1 diabetes mellitus and diabetic ketoacidosis in a regional Australian health service. J Paediatr Child Health. 2024 Nov;60(11):730-736.\u003c/li\u003e\n\u003cli\u003eLawrence C, Seckold R, Smart C, King BR, Howley P, Feltrin R, et al. Increased paediatric presentations of severe diabetic ketoacidosis in an Australian tertiary centre during the COVID‐19 pandemic. Diabetic Medicine. 2020 Oct 23;38(1).\u003c/li\u003e\n\u003cli\u003eKao, K.-T., Lei, S., Cheek, J.A., White, M. and Hiscock, H. (2024), Paediatric diabetes-related presentations to emergency departments in Victoria, Australia from 2008 to 2018. Emergency Medicine Australasia, 36: 101-109.\u003c/li\u003e\n\u003cli\u003eDuca LM, Wang B, Rewers M, Rewers A. Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes Predicts Poor Long-term Glycemic Control. Diabetes Care. 2017 Jun 30;40(9):1249\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eClapin HF, Earnest A, Colman PG, Davis EA, Jefferies C, Anderson K, et al. Diabetic Ketoacidosis at Onset of Type 1 Diabetes and Long-term HbA1c in 7,961 Children and Young Adults in the Australasian Diabetes Data Network. Diabetes Care. 2022 Dec 1;45(12):2918\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eCherubini V, Grimsmann JM, \u0026Aring;kesson K, Birkeb\u0026aelig;k NH, Cinek O, Dovč K, et al. Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: results from 13 countries in three continents. Diabetologia. 2020 May 8;63(8):1530\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eCensus of Population and Housing: Socio-Economic Indexes for Areas (SEIFA), Australia, 2016\u003c/li\u003e\n\u003cli\u003eDella Manna T, Steinmetz L, Campos PR, Farhat SCL, Schvartsman C, Kuperman H, et al. Subcutaneous Use of a Fast-Acting Insulin Analogue: An alternative treatment for pediatric patients with diabetic ketoacidosis. Diabetes Care. 2005 Jul 25;28(8):1856\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eGlaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes. 2022 Oct 17;23(7):835\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eDesai D, Mehta D, Mathias P, Menon G, Schubart UK. Health Care Utilisation and Burden of Diabetic Ketoacidosis in the U.S. Over the Past Decade: A Nationwide Analysis. Diabetes Care [Internet]. 2018 May 17 [cited 2019 Jun 20];41(8):1631\u0026ndash;8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 1 Diabetes, Diabetic Ketoacidosis, Regional Centre, Insulin","lastPublishedDoi":"10.21203/rs.3.rs-5928922/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5928922/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eAim\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo characterise the clinical and biochemical parameters of children (0\u0026ndash;16 years) who presented with Diabetic Ketoacidosis (DKA) at a regional hospital in Australia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e A retrospective observational study was conducted following the approval of the Ethics Committee. Data from 2018\u0026ndash;2022 were collected from medical records, with a focus on patient treatment and follow-up.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 72 type 1 diabetes (T1D) patients with 30 DKA presentations were identified. The mean age at DKA presentation was 11.9 +/- 3.2 years, with 42.1% having new-onset T1D. An equal number of patients presented with mild (50%) and moderate to severe DKA. Of these, 24 presentations were managed with insulin infusion, and 6 (20%) were managed with subcutaneous insulin. Following a mean ED stay of 7.93 +/- 4.8 hours, 14 patients (93.3%) were transferred to the CCU or ward, and 2 were transferred out. The mean HbA1c was 12.55 +/- 2.1%, with a mean recovery time of 10.4 hours for pH and 6.4 hours for bicarbonate. Minor complications occurred in 10% of patients (all on insulin infusion). All patients were discharged in stable condition after 2.15 +/- 1.3 days. The follow-up rate was 72.2% (13/18), with a mean Hba1c of 8.32 +/- 1.8%.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRegional hospitals witness a high frequency of children with T1D presenting with DKA as their first presentation. Targeting bicarbonate levels for acidosis correction could help facilitate an earlier transition to subcutaneous insulin and needs due consideration. This study substantiates the use of upfront subcutaneous insulin for mild to moderate DKA with good outcomes. Follow-up care remains a crucial gap that necessitates strengthening regional diabetes management teams.\u003c/p\u003e","manuscriptTitle":"Characterisation of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes: A Regional Hospital Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 12:28:20","doi":"10.21203/rs.3.rs-5928922/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-14T14:46:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-13T09:40:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-12T07:41:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187367103340155560423640724578645046141","date":"2025-04-03T19:58:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235813103109368601539728097967442297728","date":"2025-04-01T11:35:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-29T08:26:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-25T04:06:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-03-25T03:27:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b16734c-f068-4c6a-bbf3-b9d4a235a84d","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T16:04:18+00:00","versionOfRecord":{"articleIdentity":"rs-5928922","link":"https://doi.org/10.1186/s12887-025-05824-0","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-06-07 15:57:49","publishedOnDateReadable":"June 7th, 2025"},"versionCreatedAt":"2025-04-01 12:28:20","video":"","vorDoi":"10.1186/s12887-025-05824-0","vorDoiUrl":"https://doi.org/10.1186/s12887-025-05824-0","workflowStages":[]},"version":"v1","identity":"rs-5928922","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5928922","identity":"rs-5928922","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}