Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema

Variations in Management and Clinical Outcomes for Children With Diabetic Ketoacidosis in an Academic Pediatric Versus Community Emergency Department Setting

OBJECTIVES

Our objectives were to characterize variations from standardized, evidence-based guidelines in the management of pediatric patients with diabetic ketoacidosis (DKA) based on initial presentation to a tertiary pediatric emergency department (PED) versus a community emergency department (OSH) and compare clinical outcomes.

METHODS

We conducted a retrospective study on children 18 years and younger with DKA who presented to an OSH or PED over a 3-year period. Treatments monitored for variation included intravenous fluid management, insulin delivery, and sodium bicarbonate administrations. Clinical outcomes included time to anion gap correction and on insulin infusion, hypokalemia, hypoglycemia, rapid serum glucose decline, cerebral edema, mechanical ventilation, mortality, and time from initial presentation to hospital discharge.

RESULTS

Children with DKA who presented to an OSH (n = 250) were more acidotic (pH 7.11 vs. 7.13, P = 0.001) and had larger anion gaps (28.8 vs. 25.5, P < 0.001) compared with children presenting to the PED (n = 237). The OSH patients were more likely to receive larger fluid boluses (>20 cc/kg or >1000 ml, 43% vs. 4%, P < 0.001), sodium bicarbonate (5% vs. 0%, P < 0.001), and intravenous bolus insulin (28% vs. 0%, P < 0.001). The OSH group were less likely to be started on maintenance intravenous fluids (70% vs. 99%, P < 0.001) or receive potassium in maintenance intravenous fluids (14% vs. 42%, P < 0.001). The OSH group had longer anion gap correction times (754 vs. 541 mins, P < 0.001), insulin infusion times (1018 vs. 854 min, P = 0.003), and times to hospital discharge (3358 vs. 3045 mins, P < 0.001). Incidence of hypokalemia, hypoglycemia, rapid glucose decline, cerebral edema, and deaths were similar between the 2 groups.

CONCLUSIONS

Our study demonstrated significant variations in the initial management of pediatric DKA patients by OSH facilities that deviated from an evidence-based treatment pathway utilized by a PED. Statewide quality improvement initiatives could help improve the overall clinical care provided to pediatric DKA patients.

Cognitive Function in Early Onset Type 1 Diabetes in Children

OBJECTIVES

To assess cognitive function and factors affecting it in Indian children with early-onset type 1 diabetes (T1D) (less than 6 y).

METHODS

This cross-sectional, single-centre study recruited children diagnosed with T1D before 6 y of age and having a disease duration of at least 2 y, as cases. Controls were age- and sex-matched apparently healthy children or siblings. Children with birth asphyxia, intellectual disability, syndromic children, or pre-existing psychiatric illness were excluded. Enrolled children underwent cognitive assessment using Malin's Intelligence Scale for Indian Children (MISIC), and scores in various subtests were compared between cases and controls.

RESULTS

A total of 60 children were enrolled in each group. When compared to controls, cases had significantly lower scores on most subtests, verbal, performance and overall Intelligence Quotient (IQ- 100.62 ± 3.26 vs. 103.23 ± 1.22). HbA1c >9%, severe hypoglycemia and lesser duration since the last diabetic ketoacidosis (DKA) episode significantly correlated with lower neurocognitive scores.

CONCLUSIONS

Children with early onset T1D showed significant deficits in various cognitive domains and IQ. Poor glycemic control, higher glycemic variability and exposure to severe hypoglycemia are risk factors for poor cognitive outcomes in these children. Further longitudinal studies could potentially aid in a finer understanding of factors affecting cognitive functioning in T1D children in developing countries.

Correlation between Neutrophil-to-Lymphocyte Ratio and Cerebral Edema in Children with Severe Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA), a common onset modality of type 1 diabetes mellitus (T1DM), can lead, in rare instances, to the development of cerebral edema, which is the leading cause of mortality in T1DM. Aside from the identification of several demographic and clinical risk factors for cerebral edema, attention has also been drawn to the possible link between systemic inflammation and neuroinflammation. This single-center retrospective study of 98 children with severe DKA aimed to investigate the possible relationship between neutrophil-to-lymphocyte ratio NLR) levels and the presence of cerebral edema. Patients were classified into three groups: alert (n = 28), subclinical cerebral edema (n = 59), and overt cerebral edema (n = 11). Lower blood pH and elevated NLR and blood urea were correlated with the presence of cerebral edema (p < 0.001). After a multivariable risk adjustment for possible confounding factors, such as age, pH, corrected sodium, and BUN, the NLR remained positively associated with cerebral edema (p = 0.045). As such, NLR may be an additional instrument to help practitioners target patients with a higher risk of severe cerebral edema. These patients would benefit from more rigorous neurologic surveillance, enabling the prompt identification of early signs of cerebral edema.

The Evaluation and Management of Pediatric Diabetic Ketoacidosis: A Comprehensive Review

Diabetic ketoacidosis (DKA) is a common, serious acute complication in children with diabetes mellitus (DM). DKA can accompany new-onset type 1 insulin-dependent DM, or it can occur with established type 1 DM, during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. In addition, DKA episodes in children with type 2 DM are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a sizable proportion of patients with new-onset DM present with DKA. The purpose of this comprehensive review is to acquaint clinicians with details regarding the pathophysiology, treatment caveats, and potential complications of DKA.

Increased Use of Hyperosmolar Therapy for Suspected Clinically Apparent Brain Injury in Pediatric Patients with Diabetic Ketoacidosis during the Peak of the COVID-19 Pandemic

The incidence of pediatric diabetic ketoacidosis (DKA) increased during the peak of the COVID-19 pandemic. The objective of this study was to investigate whether rates of hyperosmolar therapy administration for suspected clinically apparent brain injury (CABI) complicating DKA also increased during this period as compared to the three years immediately preceding the pandemic and to compare the characteristics of patients with suspected CABI before the pandemic, patients with suspected CABI during the peak of the pandemic, and those with DKA but without suspected CABI during the pandemic. Patients aged ≤18 years presenting with DKA before (March 11, 2017-March 10, 2020) and during the peak of the pandemic (March 11, 2020-March 10, 2021) were identified through a rigorous search of two databases. Predefined criteria were used to diagnose suspected CABI. Biochemical, clinical, and sociodemographic data were collected from a comprehensive review of the electronic medical record. The proportion of patients with DKA who received hyperosmolar therapy was significantly higher (P = 0.014) during the pandemic compared to the prepandemic period; however, this was only significant among patients with newly diagnosed diabetes. Both groups with suspected CABI had more severe acidosis, lower Glasgow Coma Scale scores, and longer hospital admissions (P< 0.001 for all) than cases without suspected CABI. During the pandemic, the blood urea nitrogen concentration was significantly higher in patients with suspected CABI than those without suspected CABI, suggesting they were more severely dehydrated. The clinical, biochemical, and sociodemographic characteristics of patients with suspected CABI were indistinguishable before and during the pandemic. In conclusion, administration of hyperosmolar therapy for suspected CABI was more common during the peak of the COVID-19 pandemic, possibly a result of delayed presentation, highlighting the need for increased awareness and early recognition of the signs and symptoms of diabetes and DKA, especially during future surges of highly transmissible infections.

COGNITIVE FUNCTIONS IN CHILDREN WITH TYPE I DIABETES

OBJECTIVE

The aim: To assess the patterns and severity of cognitive impairment in children with type 1 diabetes as well as its association with disease onset and poor glycemic control.

PATIENTS AND METHODS

Materials and methods: We assessed higher mental function and screened for psychosocial functioning in 60 children with type 1 DM and 60 age-matched control using the Modified Mini-Mental State examination and Pediatric Symptoms Checklist and its relation with age, gender, socioeconomic status, age at the onset of disease, duration of disease, HbA1c level, frequency of diabetic ketoacidosis and hypoglycemic attacks and type of treatment.

RESULTS

Results: Diabetic patients demonstrated a lower Modified Mini-Mental State examination score than controls (25.12±4.58 versus 30.08±2.95) with a highly significant difference. Furthermore, the mean Pediatric symptoms checklist score in patients was 39.08±8.18 which was much lower than that of controls 54.42±6.0 with a highly significant difference.

CONCLUSION

Conclusions: There is neurocognitive impairment in diabetic children compared to non-diabetics, and poor glycemic control whether hyper or hypoglycemia could affect their cognition and mental health.

Cerebral edema associated with diabetic ketoacidosis: Two case reports

Background

Diabetic ketoacidosis (DKA) is associated with a high mortality rate, especially if cerebral edema develops during the disease course. It is rarer and more severe in adults than in children. We present cases of two patients with cerebral edema-related DKA.

Case presentation

The first patient was a 38-year-old man with diabetes mellitus who presented with DKA-related disturbed consciousness. Although glycemic correction was performed slowly, he showed pupil dilation 11 h later. He underwent emergency ventricular drainage, but died of cerebral herniation. The second patient was a 25-year-old woman who presented with impaired consciousness secondary to DKA. Head computed tomography showed subarachnoid hemorrhage and cerebral edema. No related intraoperative findings were observed; it was concluded that the first computed tomography scan revealed pseudo-subarachnoid hemorrhage.

Conclusion

Diabetic ketoacidosis-related cerebral edema develops despite treatment according to guidelines and is difficult to predict. Therefore, adult patients should be treated cautiously during DKA management.

Multimodal Neurologic Monitoring in Children With Acute Brain Injury

Children with acute neurologic illness are at high risk of mortality and long-term neurologic disability. Severe traumatic brain injury, cardiac arrest, stroke, and central nervous system infection are often complicated by cerebral hypoxia, hypoperfusion, and edema, leading to secondary neurologic injury and worse outcome. Owing to the paucity of targeted neuroprotective therapies for these conditions, management emphasizes close physiologic monitoring and supportive care. In this review, we will discuss advanced neurologic monitoring strategies in pediatric acute neurologic illness, emphasizing the physiologic concepts underlying each tool. We will also highlight recent innovations including novel monitoring modalities, and the application of neurologic monitoring in critically ill patients at risk of developing neurologic sequelae.

Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols

The best protocol for severe inaugural diabetic ketoacidosis (DKA) in children remains unclear. We compared two protocols by assessing effects during the first 24 h on osmolality, serum sodium, and glucose variations, which are associated with the risk of cerebral oedema, the most dreaded complication of DKA. We also recorded complications. We retrospectively included children aged 28 days to 18 years and admitted for severe DKA to either of two paediatric intensive care units (PICUs) in Paris (France). The two protocols differed regarding hydration volume, glucose intake, and sodium intake. From 17 June 2010 to 17 June 2015, 93 patients were included, 29 at one PICU, and 64 at the other. We compared severe glycaemic drops (> 5.5 mmol/L/h), mean glycaemia variations, serum sodium, serum osmolality, and the occurrence of cerebral oedema (CE) during the first 24 h after PICU admission. Severe glycaemic drops occurred in 70% of patients, with no between-group difference. Blood glucose, serum sodium, and serum osmolality variations were comparable. Seven (7.5%) patients were treated for suspected CE, (4 [10.3%)] and 3 [6.3%]) in each PICU; none had major residual impairments.

CONCLUSION

 The two paediatric DKA-management protocols differing in terms of fluid-volume, glucose, and sodium intakes had comparable effects on clinical and laboratory-test changes within 24 h. Major drops in glycaemia and osmolality were common with both protocols. No patients had residual neurological impairments.

WHAT IS KNOWN

• Cerebral oedema is the most severe complication of diabteic ketoacidosis in children.The risk of cerebral oedema is dependant on both patient related and treatment-related factors. • The optimal protocol for managing severe inaugural diabetic ketoacidosis in children remains unclear, and few studies have targeted this specific population.

WHAT IS NEW

• Two management protocols that complied with ISPAD guidelines but differed regarding the amounts of fluids, glucose, and sodium administered produced similar outcomes in children with severe inaugural diabetic ketoacidosis. • Cerebral oedema was rare with both protocols and caused no lasting impairments.

Bihemispheric Cerebral Oximetry Monitoring's Functionality in Suspected Cerebral Edema Diabetic Ketoacidosis With Therapeutic 3% Hyperosmolar Therapy in a Pediatric Emergency Department

BACKGROUND

Suspected cerebral edema diabetic ketoacidosis (SCEDKA) is more common than perceived with symptoms including altered mentation, headache with vomiting, depressed Glasgow coma scale (GCS), abnormal motor or verbal responses, combativeness, and neurological depression. Suspected cerebral edema diabetic ketoacidosis has been associated with initial diabetic ketoacidosis (DKA) presentation and at start of DKA therapy.Cerebral oximetry (bihemispheric regional cerebral oxygen saturation [rcSO2] and cerebral blood volume index [CBVI]) can detect increased intracranial pressure (ICP)-induced altered bihemispheric cerebral physiology (rcSO2) (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700). In pediatrics, rcSO2 of less than 60% or rcSO2 of greater than 85% reflects increased ICP and cerebral edema (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700). Cerebral oximetry can detect increased ICP-induced altered bihemispheric cerebral physiology (rcSO2, CBVI) and cerebral physiological changes (rcSO2, CBVI changes) during therapeutic mechanical cerebral spinal fluid removal to decrease increased ICP (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700).In the pediatric intensive care units, SCEDKA patients with nonbihemispheric cerebral oximetry showed an initial rcSO2 of greater than 90%. Bihemispheric rcSO2 with CBVI in SCEDKA patients has the potential to detect the abnormal cerebral physiology and disruptive autoregulation while detecting 3% hypertonic saline solution (HTS) effects on the SCEDKA altered cerebral physiology (rcSO2).

PURPOSE

The purposes of this study were to analyze and compare 3% HTS effect on bihemispheric rcSO2 readings, neurological and biochemical parameters in SCEDKA with 3% HTS infusion to non-SCEDKA patients in pediatric emergency department (PED).

METHODS

An observational retrospective comparative analysis study of bihemispheric rcSO2 readings, neurological and biochemical parameters in 2 groups of PED DKA patients were performed: PED DKA patients with SCEDKA +3% HTS infusions versus non-SCEDKA without 3% HTS infusions.

RESULTS

From 2008 to 2013, of the 1899 PED DKA patients, 60 SCEDKA patients received 3% HTS (5 mL/kg via peripheral intravenous) infusion (median age of 5 years [range, 3.7-7 years]), with 42 new DKA insulin dependent diabetes mellitus onset. Suspected cerebral edema diabetic ketoacidosis patients had GCS of 11 (range, 11-12), with consistent SCEDKA signs and symptoms (severe headaches with vomiting, confusion, blurred vision, altered speech, lethargy, and combativeness). Suspected cerebral edema diabetic ketoacidosis patients' initial (0-5 minutes) left rcSO2 readings were 91.4% (range, 88.4%-94.1%) and right was 90.3% (range, 88.6%-94.1%) compared with non-SCEDKA patients' left rcSO2 readings of 73.2% (range, 69.7%-77.8%) and right of 73.2% (range, 67.6%-77%) (P < 0.0001). The rcSO2 monitoring time before 3% HTS infusion was 54.9 minutes (range, 48.3-66.8 minutes) with 3% HTS time effect change: pre-3% HTS (54.9 minutes [range, 48.3-66.8 minutes]). Before 3% HTS infusion, the left rcSO2 readings were 90.0% (range, 89%-95%) and right was 91% (range, 86%-95%). The 30 to 45 minutes post-3% HTS showed that left was 64% (range, 62%-69%) and right was 65.4% (range, 63%-70%) (P < 0.0001). rcSO2 Δ change for post-3% HTS (0-20 minutes) to pre-3% HTS was as follows: left, -26.58 (-29.5 to -23.7) (P < 0.0001); right, -25.2 (-27.7 to -22.6) (P < 0.0001). Post-3% HTS GCS (14,15) and biochemistry compared with pre-3% HTS infusions all improved (P < 0.001).

CONCLUSIONS

In PED SCEDKA patients, the pre-3% HTS bihemispheric rcSO2 readings were greater than 90% and had lower GCS than non-SCEDKA patients. The post-3% HTS infusion rcSO2 readings showed within minutes a substantial reduction compared with non-SCEDKA patients, with no complications. Changes in rcSO2 readings after 3% HTS correlated with improved SCEDKA indicators (improved mental status, headache, and GCS) without any complications. We showed that cerebral oximetry in PED SCEDKA patients has shown an initial bihemispheric of greater than 90% readings signifying abnormal bihemispheric cerebral physiology. We also showed the cerebral oximetry's functionality in detecting 3% HTS therapeutic effects on SCEDKA's abnormal cerebral physiology and the beneficial therapeutic effects of 3% HTS infusion in SCEDKA patients. Using cerebral oximetry in pediatric DKA patients' initial cerebral assessment could have a significant impact in detecting SCEDKA patients. Further SCEDKA research using cerebral oximetry should be considered.

Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program

OBJECTIVES

The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs.

METHODS

This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores.

RESULTS

A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline.

CONCLUSIONS

This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.

Non-traumatic pediatric intracranial hypertension: key points for different etiologies, diagnosis, and treatment

Intracranial hypertension can be an acute life-threatening event or slowly deteriorating condition, leading to a gradual loss of neurological function. The diagnosis should be taken in a timely fashioned process, which mandates expedite measures to save brain function and sometimes life. An optimal management strategy is selected according to the causative etiology with a core treatment paradigm that can be utilized in various etiologies. Distinct etiologies are intracranial bleeds caused by traumatic brain injury, spontaneous intracranial hemorrhage (e.g., neonatal intraventricular hemorrhage), or the rare pediatric hemorrhagic stroke. The other primary pediatric etiologies for elevated intracranial pressure are intracranial mass (e.g., brain tumor) and hydrocephalus related. Other unique etiologies in the pediatric population are related to congenital diseases, infectious diseases, metabolic or endocrine crisis, and idiopathic intracranial pressure. One of the main goals of treatment is to alleviate the growing pressure and prevent the secondary injury to brain parenchyma due to inadequate blood perfusion and eventually inadequate parenchymal oxygenation and metabolic state. Previous literature discussed essential characteristics of the treatment paradigm derived mainly from pediatric brain traumatic injuries' treatment methodology. Yet, many of these etiologies are not related to trauma; thus, the general treatment methodology must be tailored carefully for each patient. This review focuses on the different possible non-traumatic etiologies that can lead to intracranial hypertension with the relevant modification of each etiology's treatment paradigm based on the current literature.

Bedside sonographic measurements of optic nerve sheath diameter in children with diabetic ketoacidosis

BACKGROUND

Bedside sonographic assessment of the optic nerve sheath has gained popularity for evaluating intracranial pressure in recent years.

OBJECTIVE

To investigate the bedside sonographic measurements of optic nerve sheath diameter (ONSD) and ONSD/eyeball diameter ratios, which are related with cerebral edema (CE), in children with diabetic ketoacidosis (DKA) before and after treatment.

METHODS

Children aged 12 months to 18 years, who were diagnosed with DKA were included. The ONSD was measured at 3 mm posterior to the globe in the anterior axial transbulbar view. The eyeball transverse diameter (ETD) and eyeball vertical diameter (EVD) were measured and ratios of ONSD/ETD and ONSD/EVD were calculated. Bedside ultrasound (US) examinations were performed at the beginning and at the end of fluid therapy.

RESULTS

About 43 patients were enrolled. About 12 (27.9%) patients had mild, 14 (32.6%) moderate, and 17 (39.5%) severe DKA. At baseline, the ONSD measurements and ratios were significantly higher in severe DKA group than in those with mild or moderate DKA group. All ONSD measurements, ONSD/ETD, and ONSD/EVD ratios at the end of therapy were significantly lower compared with baseline measurements. At the end of therapy, ONSD measurements and ratios were similar among DKA severity groups.

CONCLUSION

The ONSD measurements and ratios decreased from the beginning of DKA treatment, which could be considered as an indicator of an increase in intracranial pressure at the time of admission. Ocular US may serve as a promising tool to perform further risk stratification of children with DKA and to identify DKA-related CE.

Brain injury in children with diabetic ketoacidosis: Review of the literature and a proposed pathophysiologic pathway for the development of cerebral edema

Cerebral edema (CE) is a potentially devastating complication of diabetic ketoacidosis (DKA) that almost exclusively occurs in children. Since its first description in 1936, numerous risk factors have been identified; however, there continues to be uncertainty concerning the mechanisms that lead to its development. Currently, the most widely accepted hypothesis posits that CE occurs as a result of ischemia-reperfusion injury, with inflammation and impaired cerebrovascular autoregulation contributing to its pathogenesis. The role of specific aspects of DKA treatment in the development of CE continues to be controversial. This review critically examines the literature on the pathophysiology of CE and attempts to categorize the findings by types of brain injury that contribute to its development: cytotoxic, vasogenic, and osmotic. Utilizing this scheme, we propose a multifactorial pathway for the development of CE in patients with DKA.

Difference in the duration of pediatric diabetic ketoacidosis: Comparison of new-onset to known type 1 diabetes

OBJECTIVE

To compare the duration (hours until HCO3-  ≥ 15 mmol/L) of diabetic ketoacidosis (DKA) episodes that are the first manifestation of new type 1 diabetes (NT1D) and those that are a complication in patients with previously diagnosed type 1 diabetes (PT1D).

METHODS

A multicenter retrospective cohort study was designed. The duration of DKA was measured from the start of the treatment. The primary outcome was the comparison of the time needed in each group to reach HCO3-  ≥ 15 mmol/L. The secondary outcomes were the comparison of the time to reach pH ≥ 7.3 and length of hospital stay in each group. Data were analyzed with a bivariate analysis of the variables vs primary outcome. Then, a regression model was analyzed. Results There were 305 episodes included (NT1D: 115, PT1D: 190). DKA in the NT1D group lasted longer (NT1D 20 (16-19) vs PT1D 12 (8-16), hours, P < .01) with a significant difference in each level of DKA severity. This group also took longer to reach pH ≥ 7.3 (NT1D 16 (12-22) vs PT1D 9 (6-12), hours, P < .01) and had a longer hospital stay (NT1D 9 (6-12) vs PT1D 7 (4-10), hours, P < .01).

CONCLUSION

The duration of DKA is longer in patients with NT1D regardless of characteristics like DKA severity, duration of symptoms, and type of treatments received.

Hypertension during Diabetic Ketoacidosis in Children

OBJECTIVES

To characterize hemodynamic alterations occurring during diabetic ketoacidosis (DKA) in a large cohort of children and to identify clinical and biochemical factors associated with hypertension.

STUDY DESIGN

This was a planned secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a randomized clinical trial of fluid resuscitation protocols for children in DKA. Hemodynamic data (heart rate, blood pressure) from children with DKA were assessed in comparison with normal values for age and sex. Multivariable statistical modeling was used to explore clinical and laboratory predictors of hypertension.

RESULTS

Among 1258 DKA episodes, hypertension was documented at presentation in 154 (12.2%) and developed during DKA treatment in an additional 196 (15.6%), resulting in a total of 350 DKA episodes (27.8%) in which hypertension occurred at some time. Factors associated with hypertension at presentation included more severe acidosis, (lower pH and lower pCO₂), and stage 2 or 3 acute kidney injury. More severe acidosis and lower Glasgow Coma Scale scores were associated with hypertension occurring at any time during DKA treatment.

CONCLUSIONS

Despite dehydration, hypertension occurs in a substantial number of children with DKA. Factors associated with hypertension include greater severity of acidosis, lower pCO_2, and lower Glasgow Coma Scale scores during DKA treatment, suggesting that hypertension might be centrally mediated.

Diabetic Ketoacidosis Complicated by a Brain Death

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). Cerebral edema (CE) can complicate DKA management. We report a patient with no significant medical history who presented with DKA and a new-onset DM; she received the standard management with regular insulin and IV fluids, the management resulted in a rapid drop in serum osmolality, the patient`s mental status deteriorated and became nonresponsive, brain imaging confirmed CE, a few days later the patient was declared brain dead by neurology. This case highlights the importance of gradual correction of hyperosmolar conditions including hyperglycemia and urges all healthcare providers to closely trend glucose levels in the management of DKA.

A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis

BACKGROUND AND OBJECTIVES

Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness.

METHODS

We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes.

RESULTS

We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; P = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized.

CONCLUSIONS

Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.

Care of Children and Adolescents with Diabetes Mellitus and Hyperglycemia in the Inpatient Setting

PURPOSE OF REVIEW

Children and adolescents with acute hyperglycemia and diabetes mellitus frequently have acute, potentially life-threatening presentations which require high-acuity care in an inpatient and often intensive care setting. This review discusses the evaluation and care of hyperglycemia and diabetes mellitus in hospitalized children in both critical and non-critical care settings, highlighting important differences in their care relative to adults.

RECENT FINDINGS

Diabetic ketoacidosis remains highly prevalent at diagnosis among children with type 1 diabetes, and hyperglycemic hyperosmolar state is increasingly prevalent among children with type 2 diabetes. Recent clinical trials have investigated the potential benefits of various types of intravenous fluids and their rates of administration as well as the risks and benefits of intensive glucose control in critically ill children. The Endocrine Society has developed guidelines focused on managing hyperglycemic hyperosmolar state, outlining important aspects of care shown to decrease morbidity and mortality. In the non-critical illness setting, intensive therapy on newly diagnosed diabetes is increasingly recommended at the outset. With the increasing incidence of diabetes mellitus in children and adolescents, recent studies addressing acute diabetes emergencies help inform best practices for care of hospitalized children with hyperglycemia and diabetes.

Subclinical cerebral edema in diabetic ketoacidosis in children

Subclinical cerebral edema in diabetic ketoacidosis tends to manifest with subtle neurological symptoms including headache, lethargy, or disorientation and a Glasgow Coma Scale of 14-15. Treatment of subclinical cerebral edema with hyperosmolar therapy for persistent symptoms is associated with good outcomes.

Early mannitol administration improves clinical outcomes of pediatric patients with brain edema

Background: Mannitol 20% is used to treat patients with decreased consciousness and as the first line of treatment to reduce intracranial pressure (ICP). However, its application in pediatric patients is still based on minimal evidence. This study was performed to determine the predictive factors of clinical outcomes in pediatric patients with brain edema in the pediatric intensive care unit (PICU).Methods: This prospective cohort study was conducted in the PICU, Sanglah Hospital Denpasar, Bali, Indonesia. The subjects were chosen by consecutive sampling from July 2016 to July 2017. The primary outcome variable was the patient’s clinical outcome. A chi-square test was used to evaluate the association between the timing of mannitol administration and the patient’s clinical outcome. Multivariate analysis was performed on all variables with p≤0.25.Results: Forty-one patients were included in the study, 65% of them were male, 65% had good nutritional status, 90% had non-traumatic brain injury, and 73% had confirmed intracranial infection. The risk of sequelae or death for patients in a coma was 1.8 times greater than that of non-comatose patients (p=0.018; CI 95% 1.119–3.047). Based on the timing of mannitol administration from the onset of decreased consciousness, the risk of sequelae or death in patients who received mannitol after 24 hours was 2.1 times higher than that in patients who received mannitol within 24 hours (p=0.006; CI 95% 1.167–3.779). Based on multivariate analysis, only two variables were associated with the patient’s clinical outcome: pediatric Glasgow coma scale (PGCS) ≤3 (p=0.03) and timing of mannitol administration >24 hours (p=0.01).Conclusion: Early administration (<24 hours) of mannitol and high PGCS are related to favorable outcomes in patients with brain edema in the PICU.

Subarachnoid and parenchymal haemorrhages as a complication of severe diabetic ketoacidosis in a preadolescent with new onset type 1 diabetes

Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in new onset type 1 diabetes mellitus (T1DM). Children have a higher rate of neurological complications from DKA when compared to adults. The differential for sudden focal neurological deterioration in the setting of DKA is cerebral oedema followed by ischaemic and haemorrhagic stroke. Spontaneous intracranial haemorrhages can present with non-specific features frequently, for example, impaired consciousness, even when biochemical parameters are improving in the setting of DKA. We report the case of a girl with new onset T1D who presented in severe DKA and subsequently developed intracerebral parenchymal and subarachnoid haemorrhages. Our patient is unique in that no focal neurological or neuropsychological deficits have been found at 1-year follow up, compared to the literature which suggests poor outcomes. Our case contrasts with these previous cases as none of the other case reports demonstrated subarachnoid haemorrhages with survival.

Glycemic control is related to cognitive dysfunction in Chinese children with type 1 diabetes mellitus

BACKGROUND

Type 1 diabetes mellitus (T1DM) is considered a risk factor for the development of cognitive difficulties. The present study examined whether the cognitive performance of Chinese children with T1DM differs from that of healthy control (HC) children, and whether cognitive dysfunction is related to glycemic control.

METHODS

Using a cross-sectional design, cognitive tests were administered, including general intelligence tests, to pediatric T1DM patients (n = 105) and HCs (n = 90). The effects of specific diabetes-related variables, including an earlier diabetes onset (<7 years of age), severe hypoglycemia, chronic hyperglycemia, and diabetic ketoacidosis (DKA), on cognitive outcomes were examined.

RESULTS

The T1DM group had lower IQ (P = 0.001) and attention (P = 0.018) scores than the HC group. Among T1DM patients, a younger age of diabetes onset was related to poorer performance on the visuospatial perception test (P = 0.017) and delayed logical memory (P = 0.012). Greater exposure to hyperglycemia over time was associated with lower visuospatial perception (P = 0.029), and DKA had a negative effect on the IQ score (P = 0.024). Compared with the late severe hypoglycemia subgroup, the early severe hypoglycemia subgroup (<7 years old) performed worse on both immediate (P = 0.001) and delayed (P = 0.049) visual memory tests.

CONCLUSIONS

Chinese children with T1DM showed deficits in IQ and attention. Earlier age of diabetes onset, chronic hyperglycemia, and DKA affected particular cognitive domains. Early exposure to severe hypoglycemia had negative effects on visual memory.

Hyperglycemic Hyperosmolar State: A Pragmatic Approach to Properly Manage Sodium Derangements

INTRODUCTION

Although hypovolemia remains the most relevant problem during acute decompensated diabetes in its clinical manifestations (diabetic ketoacidosis, DKA, and hyperglycemic hyperosmolar state, HHS), the electrolyte derangements caused by the global hydroelectrolytic imbalance usually complicate the clinical picture at presentation and may be worsened by the treatment itself.

AIM

This review article is focused on the management of dysnatremias during hyperglycemic hyperosmolar state with the aim of providing clinicians a useful tool to early identify the sodium derangement in order to address properly its treatment.

DISCUSSION

The plasma sodium concentration is modified by most of the therapeutic measures commonly required in such patients and the physician needs to consider these interactions when treating HHS. Moreover, an improper management of plasma sodium concentration (PNa+) and plasma osmolality during treatment has been associated with two rare potentially life-threatening complications (cerebral edema and osmotic demyelination syndrome). Identifying the correct composition of the fluids that need to be infused to restore volume losses is crucial to prevent complications.

CONCLUSION

A quantitative approach based on the comparison between the measured PNa+ (PNa+ M) and the PNa+ expected in the presence of an exclusive water shift (PNa+ G) may provide more thorough information about the true hydroelectrolytic status of the patient and may therefore, guide the physician in the initial management of HHS. On the basis of data derived from our previous studies, we propose a 7-step algorithm to compute an accurate estimate of PNa+ G.

Hyperglycaemia-related complications at the time of diagnosis can cause permanent neurological disability in children with neonatal diabetes

BACKGROUND

Children with neonatal diabetes often present with diabetic ketoacidosis and hence are at risk of cerebral oedema and subsequent long-term neurological deficits. These complications are difficult to identify because neurological features can also occur as a result of the specific genetic aetiology causing neonatal diabetes.

CASE REPORTS

We report two cases of neonatal diabetes where ketoacidosis-related cerebral oedema was the major cause of their permanent neurological disability. Case 1 (male, 18 years, compound heterozygous ABCC8 mutation) and case 2 (female, 29 years, heterozygous KCNJ11 mutation) presented with severe diabetic ketoacidosis at 6 and 16 weeks of age. Both had reduced consciousness, seizures and required intensive care for cerebral oedema. They subsequently developed spastic tetraplegia. Neurological examination in adulthood confirmed spastic tetraplegia and severe disability. Case 1 is wheelchair-bound and needs assistance for transfers, washing and dressing, whereas case 2 requires institutional care for all activities of daily living. Both cases have first-degree relatives with the same mutation with diabetes, who did not have ketoacidosis at diagnosis and do not have neurological disability.

DISCUSSION

Ketoacidosis-related cerebral oedema at diagnosis in neonatal diabetes can cause long-term severe neurological disability. This will give additional neurological features to those directly caused by the genetic aetiology of the neonatal diabetes. Our cases highlight the need for increased awareness of neonatal diabetes and earlier and better initial treatment of the severe hyperglycaemia and ketoacidosis often seen at diagnosis of these children.

Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.

Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids

BACKGROUND

Pediatric diabetic ketoacidosis (DKA) is a disease associated with several complications that can be severe. One complication includes cerebral edema (CE), and patients may experience significant morbidity with this disease.

OBJECTIVE

This review evaluates the myths concerning CE in pediatric DKA including mechanism, presentation of edema, clinical assessment of dehydration, and association with intravenous (i.v.) fluids.

DISCUSSION

Multiple complications may occur in pediatric DKA. CE occurs in < 1% of pediatric DKA cases, though morbidity and mortality are severe without treatment. Several myths surround this disease. Subclinical CE is likely present in many patients with pediatric DKA, though severe disease is rare. A multitude of mechanisms likely account for development of CE, including vasogenic and cytotoxic causes. Clinical dehydration is difficult to assess. Literature has evaluated the association of fluid infusion with the development of CE, but most studies are retrospective, with no comparator groups. The few studies with comparisons suggest fluid infusion is not associated with DKA. Rather, the severity of DKA with higher blood urea nitrogen and greater acidosis contribute to CE. Multiple strategies for fluid replacement exist. A bolus of 10 mL/kg of i.v. fluid is likely safe, which can be repeated if hemodynamic status does not improve.

CONCLUSIONS

Pediatric CE in DKA is rare but severe. Multiple mechanisms result in this disease, and many patients experience subclinical CE. Intravenous fluids are likely not associated with development of CE, and 10-mL/kg or 20-mL/kg i.v. bolus is safe.

Adherence to pediatric diabetic ketoacidosis guidelines by community emergency departments' providers

Background

Diabetic ketoacidosis (DKA) is a common presentation of type I diabetes mellitus to the emergency departments. Most children with DKA are initially managed in community emergency departments where providers may not have easy access to educational resources or pediatric-specific guidelines and protocols that are readily available at pediatric academic medical centers. The aim of this study is to evaluate adherence of community emergency departments in the state of Indiana to the pediatric DKA guidelines.

Methods

We performed a retrospective chart review of patients, age 18 years of age or under, admitted to the pediatric intensive care unit with a diagnosis of DKA.

Results

A total of 100 patients were included in the analysis. Thirty-seven percent of patients with DKA were managed according to all six guideline parameters. Only 39% of patients received the recommended hourly blood glucose checks. Thirty percent of patients received intravenous insulin bolus, which is not recommended.

Conclusions

Non-adherence to pediatric DKA guidelines still exists in the state of Indiana. Further, larger studies are needed to reveal the etiology of non-adherence to pediatric DKA guidelines and strategies to improve that adherence.

Suspected Cerebral Edema in Diabetic Ketoacidosis: Is There Still a Role for Head CT in Treatment Decisions?

OBJECTIVES

Neurologic deterioration associated with cerebral edema in diabetic ketoacidosis is typically sudden in onset, progresses rapidly, and requires emergent treatment. The utility of brain imaging by head CT in decisions to treat for cerebral edema has not been previously studied. The objective of this study was to describe the characteristics of pediatric patients with diabetic ketoacidosis who develop altered mental status and evaluate the role of head CT in this cohort.

DESIGN

Retrospective analysis of clinical, biochemical, and radiologic data.

SETTING

Tertiary care children's hospital (2004-2010).

PATIENTS

Six hundred eighty-six admissions of patients (< 26 yr) with diabetic ketoacidosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Altered mental status was documented during 96 of 686 diabetic ketoacidosis admissions (14%). Compared with alert patients, those with altered mental status were younger (median, 12.0 vs 13.1 yr; p = 0.007) and more acidotic (pH, 7.04 vs 7.19; p < 0.001), with higher serum osmolality (328 vs 315 mOsm/kg; p < 0.001) and longer hospital length of stay (4.5 vs 3 d; p = 0.002). Head CT was performed during 60 of 96 diabetic ketoacidosis admissions with altered mental status (63%), 16 (27%) of which had abnormal results. Hyperosmolar therapy for cerebral edema was given during 23 of the 60 admissions (38%), during which 12 (52%) had normal head CT results, eight of these 12 (67%) after cerebral edema treatment and four (33%) before. Of the 11 admissions with abnormal head CT results that received hyperosmolar therapy, four head CT scan (36%) occurred after hyperosmolar treatment and seven (64%) before. For the 11 admissions with head CT before cerebral edema treatment, there was a median 2-hour delay between head CT and hyperosmolar therapy.

CONCLUSIONS

In this single-center retrospective study, there was no evidence that decisions about treatment of patients with diabetic ketoacidosis and suspected cerebral edema were enhanced by head CT, and head CT may have led to a significant delay in hyperosmolar therapy.

Neurological Complications of Endocrine Disease

The endocrine system is a complex group of organs and glands that relates to multiple other organs and systems in the body with the ultimate goal of maintaining homeostasis. This complex network functions through hormones excreted by several glands and released in the blood, targeting different body tissues and modulating their function. Any primary disorders affecting the endocrine glands and altering the amount of hormones synthesized and released will lead to disruption in the functions of multiple organs. The central nervous system of a developing child is particularly sensitive to endocrine disorders. A variety of neurological manifestations have been described as features of several endocrine diseases in childhood. Their knowledge may contribute to an early diagnosis of a particular endocrine condition, especially when more typical features are not present yet. In this article, we discuss specific neurological manifestations found in various endocrine disorders in children.

Incidence, Trends, and Outcomes of Cerebral Edema Among Children With Diabetic Ketoacidosis in the United States

INTRODUCTION

There are limited data regarding the incidence, trends, and outcomes of cerebral edema among patients with diabetic ketoacidosis (DKA).

METHODS

NIS database was used from year 2002 to 2012. Cases with primary diagnosis of DKA were identified using International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9 CM) code 250.1 x. Cerebral edema patients were identified using ICD-9 CM code 348.5. We compared the baseline characteristics of both groups to estimate differences using the χ(2) test, Student's t test, Wilcoxon rank-sum test, and survey regression depending on the distributions of variables. For trend analysis, the χ(2) test of trend for proportions was used using the Cochrane Armitage test via the "trend" command in Statistical Analysis Software (SAS). Multivariate odds ratios were calculated. P value for <0.05 was considered as significant for all analysis.

RESULTS

In all, 205 (weighted n = 974) cases of cerebral edema were identified among 52 049 (weighted n = 246 925) DKA patients, which estimates the incidence of cerebral edema at 0.39%. Trends of incidence of developing cerebral edema increased almost 2 times, from 0.34 in 2002 to 0.64 in 2012 (P < 0.001). Univariate analysis showed that both length of stay (LOS; 3 vs 2; P < 0.001) and cost of hospitalization ($10 530 vs $3953; P < 0.001) were statistically higher among those who developed cerebral edema.

CONCLUSION

Our study shows that over the study period, trend in incidence of cerebral edema among DKA patients has increased. Patients with cerebral edema were found to have longer LOS and higher cost of hospitalization.

A fatal outcome of complicated severe diabetic ketoacidosis in a 11-year-old girl

Diabetic ketoacidosis (DKA) is a complex metabolic state characterized by hyperglycemia, metabolic acidosis and ketonuria. Cerebral edema is the most common rare complication of DKA in children. The objective of the study was to emphasize the importance of careful evaluation and monitoring for signs and symptoms of cerebral edema in all children undergoing treatment for DKA. We present a case of 11-year-old girl with a history of diabetes mellitus type I (T1DM) who presented with severe DKA complicated by hypovolemic shock, cerebral edema and hematemesis. Considering the fact that complications of DKA are rare and require a high index of clinical suspicion, early recognition and treatment are crucial for avoiding permanent damage.

How can cerebral edema during treatment of diabetic ketoacidosis be avoided?

Cerebral edema during diabetic ketoacidosis (DKA) is a rare complication but it can be devastating, with significant mortality and long-term morbidity. Certain risk factors have been teased out with some large case-control studies, but more research needs to be done to make management guidelines safer. This article will discuss how DKA might be prevented from occurring in the first instance, known risk factors for cerebral edema, fluid and insulin management, the importance of careful monitoring during DKA treatment, and the importance of recognizing and acting on the earliest symptoms to prevent long-term harm.

Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children

OBJECTIVE

To investigate the impact of new-onset diabetic ketoacidosis (DKA) during childhood on brain morphology and function.

RESEARCH DESIGN AND METHODS

Patients aged 6-18 years with and without DKA at diagnosis were studied at four time points: <48 h, 5 days, 28 days, and 6 months postdiagnosis. Patients underwent magnetic resonance imaging (MRI) and spectroscopy with cognitive assessment at each time point. Relationships between clinical characteristics at presentation and MRI and neurologic outcomes were examined using multiple linear regression, repeated-measures, and ANCOVA analyses.

RESULTS

Thirty-six DKA and 59 non-DKA patients were recruited between 2004 and 2009. With DKA, cerebral white matter showed the greatest alterations with increased total white matter volume and higher mean diffusivity in the frontal, temporal, and parietal white matter. Total white matter volume decreased over the first 6 months. For gray matter in DKA patients, total volume was lower at baseline and increased over 6 months. Lower levels of N-acetylaspartate were noted at baseline in the frontal gray matter and basal ganglia. Mental state scores were lower at baseline and at 5 days. Of note, although changes in total and regional brain volumes over the first 5 days resolved, they were associated with poorer delayed memory recall and poorer sustained and divided attention at 6 months. Age at time of presentation and pH level were predictors of neuroimaging and functional outcomes.

CONCLUSIONS

DKA at type 1 diabetes diagnosis results in morphologic and functional brain changes. These changes are associated with adverse neurocognitive outcomes in the medium term.

Diabetic ketoacidosis in the pediatric emergency department

Despite many advances, the incidence of pediatric-onset diabetes and diabetic ketoacidosis (DKA) is increasing. Diabetes mellitus is 1 of the most common chronic pediatric illnesses and, along with DKA, is associated with significant cost and morbidity. DKA is a complicated metabolic state hallmarked by dehydration and electrolyte disturbances. Treatment involves fluid resuscitation with insulin and electrolyte replacement under constant monitoring for cerebral edema. When DKA is recognized and treated immediately, the prognosis is excellent. However, when a patient has prolonged or multiple courses of DKA or if DKA is complicated by cerebral edema, the results can be devastating.

Common endocrine issues in the pediatric intensive care unit

Thyroid hormone is central to normal development and metabolism. Abnormalities in thyroid function in North America often arise from autoimmune diseases, but they rarely present as critical illness. Severe deficiency or excess of thyroid hormone both represent life-threatening disease, which must be treated expeditiously and thoroughly. Such deficiencies must be considered, because presentation may be nonspecific.

Brain tissue oxygenation-guided management of diabetic ketoacidosis induced cerebral edema*

OBJECTIVE

Type 1 diabetes mellitus is the most common chronic disease of childhood. Diabetic ketoacidosis is a well-known complication of diabetes mellitus and can be associated with devastating cerebral edema resulting in severe long-term neurologic disability. Despite the significant morbidity and mortality associated with this condition, relatively few treatments are recommended for these patients. The authors present two patients in which they used both intracranial pressure and brain tissue oxygenation monitoring to manage diabetic ketoacidosis-associated cerebral edema with favorable neurologic outcomes.

SETTING

Pediatric intensive care unit in a tertiary care teaching hospital.

INTERVENTIONS

Two children presented to the emergency room with vague complaints and were found to have diabetic ketoacidosis. During treatment, both patients became comatose with head computed tomography scans revealing diffuse cerebral edema and herniation syndrome. Intracranial pressure and brain tissue oxygenation monitors were placed to guide therapy.

RESULTS

Multiple episodes of brain tissue hypoxia were noted in both patients. Intracranial pressure control with intubation, sedation, and hyperosmolar therapy improved episodes of decreased brain tissue oxygenation associated with intracranial hypertension. Brain tissue oxygenation was also noted to be significantly less than the target value on several occasions even when intracranial pressure was controlled and an age-appropriate cerebral perfusion pressure goal was met. Augmentation of cerebral perfusion pressure above age-appropriate goal with fluid boluses and inotropic agents increased brain tissue oxygenation in these instances. Both children had very low Glasgow Coma Scale scores at admission, but ultimately had favorable neurologic outcomes.

CONCLUSIONS

Multimodal neuromonitoring of both intracranial pressure and brain tissue oxygenation during episodes of clinically apparent diabetic ketoacidosis-associated cerebral edema allows for the detection and treatment of episodes of elevated intracranial pressure and/or brain tissue hypoxia that may be of clinical significance.

Current concepts and controversies in prevention and treatment of diabetic ketoacidosis in children

Diabetic ketoacidosis (DKA) is caused by absolute or relative lack of insulin. Lack of insulin leads to hyperglycemia, ketonemia, and acidosis. Prevalence of DKA at diagnosis of type 1 diabetes (T1D) varies around the world from 18 % to 84 %. Incidence of recurrent DKA is higher among females, insulin pump users, those with a history of psychiatric or eating disorder, and suboptimal socioeconomic circumstances. DKA is the most common cause of death in children with T1D. Children with DKA should be treated in experienced centers. Initial bolus of 10-20 mL/kg 0.9 % saline is followed by 0.45 %-0.9 % saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours. The prevention of DKA at diagnosis of diabetes can be achieved by an intensive community intervention and education of health care providers to raise awareness. Prevention of recurrent DKA requires continuous patient education and access to diabetes programs and telephone services.

Fulminant type 1 diabetes mellitus

We present a fatal case of fulminant type 1 diabetes mellitus that was initially diagnosed as upper respiratory tract infection based on pharyngeal redness at a clinic. However, the patient then went into cardiopulmonary arrest, and was transferred to our hospital for treatment. Testing revealed very high levels of blood glucose (86.9 mmol/l), urinary glucose (2+) and ketones (4+). His glycosylated haemoglobin level was almost normal (6.2%; normal <6.2%). Autopsy revealed marked depletion and atrophy of the islets of Langerhans.

Brain edema in diseases of different etiology

Cerebral edema is a potentially life-threatening complication shared by diseases of different etiology, such as diabetic ketoacidosis, acute liver failure, high altitude exposure, dialysis disequilibrium syndrome, and salicylate intoxication. Pulmonary edema is also habitually present in these disorders, indicating that the microcirculatory disturbance causing edema is not confined to the brain. Both cerebral and pulmonary subclinical edema may be detected before it becomes clinically evident. Available evidence suggests that tissue hypoxia or intracellular acidosis is a commonality occurring in all of these disorders. Tissue ischemia induces physiological compensatory mechanisms to ensure cell oxygenation and carbon dioxide removal from tissues, including hyperventilation, elevation of red blood cell 2,3-bisphosphoglycerate content, and capillary vasodilatation. Clinical, laboratory, and necropsy findings in these diseases confirm the occurrence of low plasma carbon dioxide partial pressure, increased erythrocyte 2,3-bisphosphoglycerate concentration, and capillary vasodilatation with increased vascular permeability in all of them. Baseline tissue hypoxia or intracellular acidosis induced by the disease may further deteriorate when tissue oxygen requirement is no longer matched to oxygen delivery resulting in massive capillary vasodilatation with increased vascular permeability and plasma fluid leakage into the interstitial compartment leading to edema affecting the brain, lung, and other organs. Causative factors involved in the progression from physiological adaptation to devastating clinical edema are not well known and may include uncontrolled disease, malfunctioning adaptive responses, or unknown factors. The role of carbon monoxide and local nitric oxide production influencing tissue oxygenation is unclear.

Risk factors for cerebral edema in diabetic ketoacidosis in a developing country: role of fluid refractory shock

OBJECTIVES

To study the clinical profile and risk factors of cerebral edema in children with diabetic ketoacidosis with specific reference to fluid refractory shock.

DESIGN

Retrospective review of medical records.

SETTING

Twelve-bed pediatric intensive care unit of a teaching hospital.

PATIENTS

Seventy-seven patients admitted to pediatric intensive care unit with a diagnosis of diabetic ketoacidosis over 5 yrs.

INTERVENTION

Medical records were reviewed, and data with respect to patients' age, clinical features, biochemical profile (blood glucose, osmolality, electrolytes, urea, creatinine, arterial pH, PaCO(2), and HCO(3) at admission, 6-12 hrs, 24 hrs, and beyond 24 hrs), cerebral edema, presence of sepsis and shock, treatment details, and primary outcome in terms of survival or death were retrieved. Patients with and without cerebral edema were compared. Variables that were significant on univariate analysis were entered in a multiple logistic regression analysis to determine the predictors for cerebral edema. Odds ratio and 95% confidence interval were calculated using SPSS version 15.

MEASUREMENTS AND MAIN RESULTS

Mean age of the patients was 5.6 (standard deviation, 3.8) years. Fifty-five (71.4%) patients had new-onset diabetes mellitus. Cerebral edema was seen in 20 patients (26%). Blood glucose, serum osmolality, and CO(2) values at admission and rate of decline in glucose and osmolality during the first 12 hrs were similar in the cerebral edema and noncerebral edema groups. On multiple logistic regression analysis, fluid refractory shock (odds ratio, 7.3; 95% confidence interval, 1.3-41; p = .025) and presence of azotemia (odds ratio, 4.3; 95% confidence interval, 1.1-16; p = .034) at admission were predictors for development of cerebral edema. Mortality in cerebral edema group was 25% as compared to 3% in the noncerebral edema group.

CONCLUSIONS

Patients with fluid refractory shock and azotemia at admission had higher odds for development of cerebral edema. Initial blood glucose, effective osmolality, or decline in glucose and osmolality had no association with cerebral edema.