Abstracts

Rationale: Successful seizure control in children already established on the classic ketogenic diet relies on proper diet implementation, strict adherence and laboratory monitoring. The aim of this study is to evaluate opportunities for quality improvement among hospitalized children on established ketogenic diet. Methods: This is a retrospective chart review of children on established classic ketogenic diet admitted to the Mayo Eugenio Children's Hospital in Rochester, MN between November 2008 and February 2012. An "admission" was defined as the period during which a given hospital service was responsible for the patient's care, regardless of whether the patient was coming from home or transferred from another service. Admissions were stratified according to indication and admitting services. Inpatient records were reviewed for serum beta-hydroxybutyrate (BHB), urine ketones, dietetics and pharmacy consultations, and administration of high-carbohydrate medications or dextrose-containing fluids. Results: Fourteen children (male 46%; median age 75 months; range 12 - 166 months) on established classic ketogenic diet were hospitalized during the study period. A total of 46 admissions were reviewed, including 20 admissions (43%) for seizure exacerbation. Admitting pediatric services included general hospital service (19), intensive care unit (18), pediatric epilepsy monitoring (6), surgical subspecialties (2), and physical medicine/ rehabilitation (1). Urine ketones were performed daily in 17 (37%) of all admissions, 10/19 (53%) admissions to general pediatric floor and 4/18 (22%) admissions to intensive care unit. Among admissions for breakthrough seizures, urine ketones were checked less than daily in 10/20 (50%) admissions and were never checked in 5/20 (25%) admissions. Among admissions for reasons other than immediate seizure control, only 7/26 (27%) had daily urine ketones monitored. Fourteen admissions had BHB testing recorded, and only 3/14 (21%) were in therapeutic range. Two of these admissions were to the Epilepsy Monitoring Unit, and one was to the General Pediatric service for medical issues unrelated to seizure. There were 3 administrations of high carbohydrate-containing medication during hospitalization and no administration of dextrose-containing fluid. All admissions but one were reviewed by a dietician within 24 hours. Medication reconciliation by a pharmacist was performed in 37/46 (80%) admissions. Conclusions: Insufficient laboratory monitoring in hospitalized children on established classic ketogenic diet occurs in about two thirds of patients requiring hospitalization, providing an opportunity for quality improvement in the care of these patients. Particular areas for attention include critical care admissions and patients admitted for reason other than seizure.