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Diabetic Ketoacidosis

- Annexes

Annex Table 1.

Declaration of Conflict of Interests

The members of the guideline development/ adaptation group and the external review group have no academic, financial, or competing interests to declare and none of them were involved in the development of the original source guideline(s).

Any identified potential COI has been reported below.

 

Egyptian Pediatric Clinical Practice Guidelines Committee (EPG)

Guideline Adaptation Group (Clinical subgroup)

 

 

Name

Affiliation, Area of expertise / Role, Country / Primary location [work]

Declaration of interests

 

 

Interest

identified

Management plan & decision

 

 

Prof. Mona Mamdouh Hassan

Pediatrics Department, Consultant, Cairo University

 

 

Ass. Prof. Amal Gaber Mohamed

Pediatrics Department, Consultant, Al-Azhar University

 

 

Prof. Amany Kamal El-Hawary

Pediatrics Department, Consultant, Mansoura University

 

 

Prof. Amina M. Abdel Wahab

Pediatrics Department, Consultant, Suez Canal University

 

 

Prof. Ashraf A. Elsharkawy

Pediatrics Department, Consultant, Mansoura University

 

 

Prof. Basma Abd-Elmoez

Pediatrics Department, Consultant, Minia University

 

 

Dr. Eman Elshanawany

 

Pediatrics Department, Consultant, Benha University

 

 

Prof. Ghada Anwar

Pediatrics Department, Cairo University

 

 

Prof. Hanaa Abdellateef Mohamad

Pediatrics Department, Consultant, Assiut University

 

 

Ass. Prof. Hanan Hassan Aly

Pediatrics Department, Consultant, Ain Shams University

 

 

Prof. Hoda Atwa

Pediatrics Department, Consultant, Suez Canal University

 

 

Prof. Lubna Fawaz

Pediatrics Department, Consultant, Cairo University

 

 

Dr. Mariam Nader Moawad,

Department of Pediatrics,Consultant,  Armed Forces College of Medicine

 

 

Dr. Marian Fares Nashed

Department of Pediatrics,Consultant,  Armed Forces College of Medicine

 

 

Ass. Prof. Mona Karem Amin

Pediatrics Department, Consultant, Suez Canal University

 

 

Prof. Nora E Badawi

Pediatrics Department, Consultant, Cairo University

 

 

Ass. Prof. Nouran Y Salah El-Din

Department of Pediatrics, Ain Shams University

 

 

Dr. Ramy Saleh Morsy

Department of Pediatrics, Consultant,  Armed Forces College of Medicine

 

 

Prof. Randa M. Matter

Pediatrics Department, Consultant, Ain Shams University

 

 

Ass. Prof. Remon M. Yousef

Department of Pediatrics, Consultant, Fayoum University

 

 

Prof. Sabry M Ghanem

Department of Pediatrics, Consultant, Al-Azhar  University

 

 

Prof. Safinaz El Habashy

Department of Pediatrics, Consultant, Ain Shams University

 

 

Ass. Prof. Shaymaa Elsayed Abdel Meguid

Department of Pediatrics, Consultant, Alexandria University

 

 

Prof. Wiam Al Farouk Younis

Department of Pediatrics,Consultant,  Armed Forces College of Medicine

 

 

Dr. Hamed Khaled  Khalifa

M.B.B.Ch Misr University for Science and Technology.

House Officer, Pediatrics Department, Cairo University.

 

 

 

Prof. Tarek Omar

Pediatrics Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Alexandria Center for Evidence-Based CPG

Consultancy Board, EPG, Egypt

Professor of Pediatrics, Methodology Supervision Subgroup

 

 

 

None

Not Applicable

 

 

Guideline Adaptation Group (Methodology Subgroup)

 

 

Prof. Ashraf Abdel Baky

Professor of Pediatrics

Ain Shams University, Egypt

Founder and Chair of EPG

None

Not Applicable

 

 

Dr. Yasser Sami Amer

1. Pediatrics Department and Clinical Practice Guidelines and Quality Research Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia;

2. Research Chair for Evidence-Based Health Care and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia;

3. Chair, Adaptation Working Group, Guidelines International Network (GIN), Perth, Scotland

4. Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, São Paulo, Brazil.

None

Not Applicable

 

 

Dr. Nahla Gamaleldin

Lecturer of pediatrics, Faculty of Medicine, Modern University for Technology and Information (MTI), Egypt

None

Not Applicable

 

 

External Review Group

 

 

Prof. Ghada Anwar

Pediatrics Department, Cairo University/ Egypt

 

 

Prof. Mona Hafez

Pediatrics Department, Cairo University/ Egypt

 

 

Prof. Mona Salem

Pediatrics Department, Ain Shams University/ Egypt

 

 

Prof. Nermin Salah

Pediatrics Department, Cairo University/ Egypt

 

 

Hesham El Hefnawy

Prof. of diabetes and endocrinology, former dean of the National Institute of Diabetes and Endocrinology, Cairo, Egypt. Head of National Committee of non-communicable disease

 

 

External Reviewer for methodology

 

Prof. Iván D. Flórez

Department of Pediatrics, University of Antioquia, Medellín, Colombia,

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada,

Leader, AGREE Collaboration (Appraisal of Guidelines for Research & Evaluation)

Director, Cochrane Colombia

 

Prof. Airton Tetelbom Stein

 

Professor Titular de Saúde Coletiva, Fundação Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil

Professor Adjunto, Universidade Luterana do Brasil (Ulbra), Canoas, Brazil

Coordenador de Diretrizes Clínicas, Grupo Hospitalar Conceição, Porto Alegre, Brazil

4. Member, Board of Trustees, Guidelines International Network (G-I-N)

 

 

International Peer Reviewers

 

 

 

 

 

 

None

Not Applicable

 

 

➡️Web annexes

The following annexes can be added as a package of standalone supplementary documents.

➡️Keywords: The MeSH terms for "Guideline for the prevention and management of DKA’’" on PubMed are: DKA, pediatrics, diagnosis, management


Prof. Ghada Anwar

Pediatrics Department, Cairo University/ Egypt

Prof. Mona Hafez

Pediatrics Department, Cairo University/ Egypt

Prof. Mona Salem

Pediatrics Department, Ain Shams University/ Egypt

Prof. Nermin Salah

Pediatrics Department, Cairo University/ Egypt

Hesham El Hefnawy

Prof. of diabetes and endocrinology, former dean of the National Institute of Diabetes and Endocrinology, Cairo, Egypt. Head of National Committee of non-communicable disease


Appendix 1. List of the websites and databases we searched:

CPG databases and libraries:

1.     Guidelines International Network (GIN) International Guidelines Library.

https://g-i-n.net/international-guidelines-library/

2.     ECRI Guidelines Trust (USA). https://guidelines.ecri.org/ 

3.     National Institute of Clinical and Health Excellence (NICE) UK. http://www.nice.org.uk/guidance/

4.     Scottish Intercollegiate Guidelines Network (SIGN) UK. http://www.sign.ac.uk/guidelines/

5.     EBSCO DynaMed (USA) https://www.dynamed.com/ (subscription required)

Bibliographic databases:

1.     PubMed/ MEDLINE https://pubmed.ncbi.nlm.nih.gov/

2.     Embase https://www.embase.com/landing?status=grey (subscription required)

3.     CINAHL https://www.ebsco.com/products/research-databases/cinahl-complete

Specialized professional societies:

1.     American Academy of Pediatrics (AAP) https://www.aap.org/

2.     Canadian Paediatric Society (CPS) https://www.cps.ca/

Royal College of Paediatrics and Child Health (RCPCH) https://www.rcpch.ac.uk/

Annex Table 2. Results of the AGREE II assessment of the three source guidelines for DKA management

CPGs

AGREE II DOMAINS

CPG1

CPG2

CPG3

CPG4

CPG5

D1: Scope & Purpose

60%

53%

61%

99%

67%

D2: Stakeholder Involvement

38%

43%

36%

94%

69%

D3: Rigour of Development

15%

9%

26%

99%

60%

D4: Clarity & Presentation

65%

68%

78%

100%

94%

D5: Applicability

9%

7%

20%

96%

74%

D6: Editorial Independence

56%

56%

4%

90%

71%

OA 1

33%

38%

38%

100%

75%

OA 2 (Recommend for use)

No (4)

No (4)

No (4)

Yes (4)

Yes (3)

Yes with modif. (1)

This table uses the AGREE II Domain Score Color codes (< 40% red; > 41 – 70% yellow; > 71 % green)

 


Annex Table 3. Annex Nurses and Parents Educational Guide in Arabic

Appendix Table 4. The RIGHT-Ad@pt checklist

7 sections, 27 topics, and 34 items

Assessment

Page(s)*

Note(s)

BASIC INFORMATION

Title/subtitle

1

Identify the report as an adaptation of practice guideline(s), that is include "guideline adaptation", "adapting", "adapted guideline/recommendation(s)", or similar terminology in the title/subtitle.

Yes

No

Unclear

 

 

2

Describe the topic/focus/scope of the adapted guideline.

Yes

No

Unclear

 

 

Cover/first page

3

Report the respective dates of publication and the literature search of the adapted guideline.

Yes

No

Unclear

 

 

4

Describe the developer and country/region of the adapted guideline.

Yes

No

Unclear

 

 

Executive summary/abstract

5

Provide a summary of the recommendations contained in the adapted guideline.

Yes

No

Unclear

 

 

Abbreviations and acronyms

6

Define key terms and provide a list of abbreviations and acronyms (if applicable).

Yes

No

Unclear

 

 

Contact information of the guideline adaptation group

7

Report the contact information of the developer of the adapted guideline.

Yes

No

Unclear

 

 

SCOPE

Source guideline(s)

8

Report the name and year of publication of the source guideline(s), provide the citation(s), and whether source authors were contacted.

Yes

No

Unclear

 

 

Brief description of the health problem(s)

9

Provide the basic epidemiological information about the problem (including the associated burden), health systems relevant issues, and note any relevant differences compared to the source guideline(s).

 

Yes

No

Unclear

 

 

Aim(s) and specific objectives

10

Describe the aim(s) of the adapted guideline and specific objectives, and note any relevant differences compared to the source guideline(s).

Yes

No

Unclear

 

 

Target population(s)

11

Describe the target population(s) and subgroup(s) (if applicable) to which the recommendation(s) is addressed in the adapted guideline, and note any relevant differences compared to the source guideline(s).

Yes

No

Unclear

 

 

End-users and settings

12

Describe the intended target users of the adapted guideline, and note any relevant differences compared to the source guideline(s).

Yes

No

Unclear

 

 

13

Describe the setting(s) for which the adapted guideline is intended, and note any relevant differences compared to the source guideline(s).

Yes

No

Unclear

 

 

RIGOR OF DEVELOPMENT

Guideline adaptation group

14

List all contributors to the guideline adaptation process and describe their selection process and responsibilities.

Yes

No

Unclear

 

 

Adaptation framework/methodology

15

Report which framework or methodology was used in the guideline adaptation process.

Yes

No

Unclear

 

 

Source guideline(s)

16

Describe how the specific source guideline(s) was(were) selected.

Yes

No

Unclear

 

 

Key questions

17

State the key questions of the adapted guideline using a structured format, such as PICO (population, intervention, comparator, and outcome), or another format as appropriate.

Yes

No

Unclear

 

 

18

Describe how the key questions were developed/modified, and/or prioritized.

Yes

No

Unclear

 

 

Source recommendation(s)

19

Describe how the recommendation(s) from the source guideline(s) was(were) assessed with respect to the evidence considered for the different criteria, the judgements and considerations made by the original panel.

Yes

No

Unclear

 

 

Evidence synthesis

20

Indicate whether the adapted recommendation(s) is/are based on existing evidence from the source guideline(s), and/or additional evidence.

Yes

No

Unclear

 

 

21

If new research evidence was used, describe how it was identified and assessed.

Yes

No

Unclear

NA

 

Assessment of the certainty of the body of evidence and strength of recommendation

22

Describe the approach used to assess the certainty/quality of the body/ies of evidence and the strength of recommendations in the adapted guideline and note any differences (if applicable) compared to the source guideline(s).

Yes

No

Unclear

NA

 

Decision-making processes

23

Describe the processes used by the guideline adaptation group to make decisions, particularly the formulation of recommendations.

 

Yes

No

Unclear

 

 

RECOMMENDATIONS

Recommendations

24

Report recommendations and indicate whether they were adapted, adopted, or de novo.

Yes

No

Unclear

 

 

25

Indicate the direction and strength of the recommendations and the certainty/quality of the supporting evidence and note any differences compared to the source recommendations(s) (if applicable).

Yes

No

Unclear

 

 

26

Present separate recommendations for important subgroups if the evidence suggests important differences in factors influencing recommendations and note any differences compared to the source recommendations(s) (If applicable).

Yes

No

Unclear

 

 

Rationale/explanation for recommendations

27

Describe the criteria/factors that were considered to formulate the recommendations or note any relevant differences compared to the source guideline(s) (if applicable).

Yes

No

Unclear

 

 

EXTERNAL REVIEW AND QUALITY ASSURANCE

External review

28

Indicate whether the adapted guideline underwent an independent external review. If yes, describe the process.

Yes

No

Unclear

 

 

Organizational approval

29

Indicate whether the adapted guideline obtained organizational approval. If yes, describe the process.

Yes

No

Unclear

SNS  & NEBMC

 

FUNDING, DECLARATION, AND MANAGEMENT OF INTEREST

Funding source(s) and funder role(s)

30

Report all sources of funding for the adapted guideline and source guideline(s), and the role of the funders.

Yes

No

Unclear

 

 

Declaration and management of interests

31

Report all conflicts of interest of the adapted and the source guideline(s) panels, and how they were evaluated and managed.

Yes

No

Unclear

 

 

OTHER INFORMATION

Implementation

32

Describe the potential barriers and strategies for implementing the recommendations (if applicable).

Yes

No

Unclear

 

 

Update

33

Briefly describe the strategy for updating the adapted guideline (if applicable).

Yes

No

Unclear

 

 

Limitations and suggestions for further research

34

Describe the challenges of the adaptation process, the limitations of the evidence, and provide suggestions for future research.

Yes

No

Unclear

--

 

 

Implementation tools:


Figure (1): Pathophysiology of diabetic ketoacidosis.

Copyright, 2006 American Diabetes Association. From Diabetes Care,

 Vol. 29, 2006:1150–9. ISPAD 2018



Figure (2): Algorithm for the management of DKA

Pinhas-Hamiel O, Sperling M. Diabetic ketoacidosis. In: Hochberg Z, ed. Practical Algorithms in Pediatric Endocrinology. 3rd, revised edition ed. Basel: Karger; 2017:112-113

 

·   Figure (3): ECG findings in hypo- and hyperkalemia.

 

Table (2): Losses of fluids and electrolytes in diabetic ketoacidosis and maintenance requirements in normal children.

(ISPAD clinical practice consensus guidelines 2018, Pediatric Diabetes October 2018; 19 (Suppl.27): 155-177).


Table (3): Glasgow Coma Scale

Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale Lancet 1974: 2: 81–4



Table (4): An alternative example of fluid volumes for the subsequent phase of rehydration. Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State: A Consensus Statement from the International Society for Pediatric and Adolescent Diabetes. Pediatric Diabetes 2018; 19 (Suppl 27): 155

 

Table (5): Determining Clinical cerebral edema risk.

Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral Edema in Childhood Diabetic Ketoacidosis: Natural history, radiographic findings, and early identification. Diabetes Care. 2004; 27 (7):1541-1546.


*One diagnostic criterion, or two major criteria, or one major and two minor criteria have a sensitivity of 92%, a specificity of 96% and a false positive rate of only 4% for the early recognition of DKA-related cerebral edema; early enough to allow for effective treatment.

 

Figure (4): Agree II Score for ISPAD Clinical Consensus Guidelines 20181


Follow up sheet for DKA ,DEMPU1    Table (6)   


Instructions in Arabic for Family and Patient Education

From DEMPU Diabetes Education Booklet, Cairo University

كتيب التقيف لسكر الأطفال و الشباب بوحدة السكر و الغدد الصماء و الميتابوليزم، مستشفى الأطفال- جامعة القاهرة، اعداد د سحر أبو الليل، مراجعة أ.د.نرمين صلاح.

 رقم ايداع2008/ 19133 

: ص 28-30









Annex Table 4. The RIGHT-Ad@pt checklist

7 sections, 27 topics, and 34 items

Assessment

Page(s)*

Note(s)

BASIC INFORMATION

Title/subtitle

1

Identify the report as an adaptation of practice guideline(s), that is include "guideline adaptation", "adapting", "adapted guideline/recommendation(s)", or similar terminology in the title/subtitle.

☒ Yes

☐ No

☐ Unclear

 

 

2

Describe the topic/focus/scope of the adapted guideline.

☒ Yes

☐ No

☐ Unclear

 

 

Cover/first page

3

Report the respective dates of publication and the literature search of the adapted guideline.

☒ Yes

☐ No

☐ Unclear

 

 

4

Describe the developer and country/region of the adapted guideline.

☒ Yes

☐ No

☐ Unclear

 

 

Executive summary/abstract

5

Provide a summary of the recommendations contained in the adapted guideline.

☒ Yes

☐ No

☐ Unclear

 

 

Abbreviations and acronyms

6

Define key terms and provide a list of abbreviations and acronyms (if applicable).

☒ Yes

☐ No

☐ Unclear

 

 

Contact information of the guideline adaptation group

7

Report the contact information of the developer of the adapted guideline.

☒ Yes

☐ No

☐ Unclear

 

 

SCOPE

Source guideline(s)

8

Report the name and year of publication of the source guideline(s), provide the citation(s), and whether source authors were contacted.

☒ Yes

☐ No

☐ Unclear

 

 

Brief description of the health problem(s)

9

Provide the basic epidemiological information about the problem (including the associated burden), health systems relevant issues, and note any relevant differences compared to the source guideline(s).

 

☒ Yes

☐ No

☐ Unclear

 

 

Aim(s) and specific objectives

10

Describe the aim(s) of the adapted guideline and specific objectives, and note any relevant differences compared to the source guideline(s).

☒ Yes

☐ No

☐ Unclear

 

 

Target population(s)

11

Describe the target population(s) and subgroup(s) (if applicable) to which the recommendation(s) is addressed in the adapted guideline, and note any relevant differences compared to the source guideline(s).

☒ Yes

☐ No

☐ Unclear

 

 

End-users and settings

12

Describe the intended target users of the adapted guideline, and note any relevant differences compared to the source guideline(s).

☒ Yes

☐ No

☐ Unclear

 

 

13

Describe the setting(s) for which the adapted guideline is intended, and note any relevant differences compared to the source guideline(s).

☒ Yes

☐ No

☐ Unclear

 

 

RIGOR OF DEVELOPMENT

Guideline adaptation group

14

List all contributors to the guideline adaptation process and describe their selection process and responsibilities.

☒ Yes

☐ No

☐ Unclear

 

 

Adaptation framework/methodology

15

Report which framework or methodology was used in the guideline adaptation process.

☒ Yes

☐ No

☐ Unclear

 

 

Source guideline(s)

16

Describe how the specific source guideline(s) was(were) selected.

☒ Yes

☐ No

☐ Unclear

 

 

Key questions

17

State the key questions of the adapted guideline using a structured format, such as PICO (population, intervention, comparator, and outcome), or another format as appropriate.

☒ Yes

☐ No

☐ Unclear

 

 

18

Describe how the key questions were developed/modified, and/or prioritized.

☐ Yes

☒ No

☐ Unclear

 

 

Source recommendation(s)

19

Describe how the recommendation(s) from the source guideline(s) was(were) assessed with respect to the evidence considered for the different criteria, the judgements and considerations made by the original panel.

☐ Yes

☒ No

☐ Unclear

 

 

Evidence synthesis

20

Indicate whether the adapted recommendation(s) is/are based on existing evidence from the source guideline(s), and/or additional evidence.

☐ Yes

☒ No

☐ Unclear

NA

 

21

If new research evidence was used, describe how it was identified and assessed.

☐ Yes

☒ No

☐ Unclear

NA

 

Assessment of the certainty of the body of evidence and strength of recommendation

22

Describe the approach used to assess the certainty/quality of the body/ies of evidence and the strength of recommendations in the adapted guideline and note any differences (if applicable) compared to the source guideline(s).

☐ Yes

☒ No

☐ Unclear

NA

 

Decision-making processes

23

Describe the processes used by the guideline adaptation group to make decisions, particularly the formulation of recommendations.

 

☒ Yes

☐ No

☐ Unclear

 

 

RECOMMENDATIONS

Recommendations

24

Report recommendations and indicate whether they were adapted, adopted, or de novo.

☒ Yes

☐ No

☐ Unclear

 

 

25

Indicate the direction and strength of the recommendations and the certainty/quality of the supporting evidence and note any differences compared to the source recommendations(s) (if applicable).

☒ Yes

☐ No

☐ Unclear

 

 

26

Present separate recommendations for important subgroups if the evidence suggests important differences in factors influencing recommendations and note any differences compared to the source recommendations(s) (If applicable).

☒ Yes

☐ No

☐ Unclear

 

 

Rationale/explanation for recommendations

27

Describe the criteria/factors that were considered to formulate the recommendations or note any relevant differences compared to the source guideline(s) (if applicable).

☒ Yes

☐ No

☐ Unclear

 

 

EXTERNAL REVIEW AND QUALITY ASSURANCE

External review

28

Indicate whether the adapted guideline underwent an independent external review. If yes, describe the process.

☒ Yes

☐ No

☐ Unclear

 

 

Organizational approval

29

Indicate whether the adapted guideline obtained organizational approval. If yes, describe the process.

☒ Yes

☐ No

☐ Unclear

 

 

FUNDING, DECLARATION, AND MANAGEMENT OF INTEREST

Funding source(s) and funder role(s)

30

Report all sources of funding for the adapted guideline and source guideline(s), and the role of the funders.

☒ Yes

☐ No

☐ Unclear

 

 

Declaration and management of interests

31

Report all conflicts of interest of the adapted and the source guideline(s) panels, and how they were evaluated and managed.

☒ Yes

☐ No

☐ Unclear

 

 

OTHER INFORMATION

Implementation

32

Describe the potential barriers and strategies for implementing the recommendations (if applicable).

☒ Yes

☐ No

☐ Unclear

 

 

Update

33

Briefly describe the strategy for updating the adapted guideline (if applicable).

☒ Yes

☐ No

☐ Unclear

 

 

Limitations and suggestions for further research

34

Describe the challenges of the adaptation process, the limitations of the evidence, and provide suggestions for future research.

☒ Yes

☐ No

☐ Unclear

61