Intermittent Phosphate Usage for Pediatric Diabetic Ketoacidosis in the Setting of a Phosphate Shortage

Abstract

Purpose: Hypophosphatemia during pediatric diabetic ketoacidosis (DKA) is often replaced through a continuous infusion of intravenous (IV) fluids with potassium phosphate. In 2012, during an IV potassium phosphate shortage, providers were directed to oral replacement strategies to restrict IV products to those patients with severe hypophosphatemia. Intermittent oral and IV as needed doses for low phosphate levels replaced continuous administration in pediatric DKA. The purpose of this quality-improvement project was to determine whether the implemented IV phosphate restrictions resulted in less IV phosphate usage with no change in clinically relevant outcomes. Methods: In a retrospective chart analysis, pediatric patients less than 18 years of age admitted with a DKA diagnosis from June 2011 to December 2016 were divided into 2 groups: continuous and intermittent phosphate administration. Patients were excluded if they received both therapies. The primary outcome was the difference in IV phosphate administered. Secondary outcomes included the following: total phosphate received, the number of patients requiring as needed doses, phosphate levels at admission and discharge from pediatric intensive care unit (PICU), hospital length of stay, and PICU length of stay. Results: Phosphate restrictions resulted in a significantly lower usage of IV phosphate products in the intermittent group versus the continuous group (38.5 vs. 0 mmol, P < .0001). While total phosphate replacement was similar, intermittent phosphate administration was also associated with significantly lower minimum and discharge phosphate levels. Conclusions: During a phosphate salt shortage, restriction of continuous phosphate replacement in pediatric DKA management can reduce the amount of IV phosphate products used without any clinically meaningful change in outcomes.