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

Impact of Charlson Comorbidity Index on in-hospital mortality of patients with hyperglycemic crises: A propensity score matching analysis

AIM

This study was designed to investigate the association between Charlson Comorbidity Index (CCI) and in-hospital mortality and other clinical outcomes among patients with hyperglycemic crises.

METHOD

This retrospective cohort study was conducted using data from electric medical records. A total of 1668 diabetic patients with hyperglycemic crises from six tertiary hospitals met the inclusion criteria. CCI < 4 was defined as low CCI and CCI ≥ 4 was defined as high CCI. Propensity score matching (PSM) with the 1:1 nearest neighbour matching method and the caliper value of 0.02 was used to match the baseline characteristics of patients with high CCI and low CCI to reduce the confounding bias. In-hospital mortality, ICU admission, hypoglycemia, hypokalemia, acute kidney injury, length of stay (LOS), and hospitalisation expense between low CCI and high CCI were compared and assessed. Univariate and multivariate regression were applied to estimate the impact of CCI on in-hospital and other clinical outcomes.

OUTCOME

One hundred twenty-one hyperglycemic crisis (HC) patients died with a mortality rate of 7.3%. After PSM, compared with low CCI, patients with high CCI suffered higher in-hospital mortality, ICU admission, LOS, and hospitalisation expenses. After multivariate regression, age (aOR: 1.12, 95% confidence interval [CI]: 1.06-1.18, p < 0.001), CCI(aOR: 4.42, 95% CI: 1.56-12.53, p = 0.005), uninsured (aOR: 22.32, 95% CI: 4.26-116.94, p < 0.001), shock (aOR: 10.57, 95% CI: 1.41-79.09, p = 0.022), mechanical ventilation (aOR: 75.29, 95% CI: 12.37-458.28, p < 0.001), and hypertension (aOR: 4.34, 95% CI: 1.37-13.82, p = 0.013) were independent risk factors of in-hospital mortality of HC patients. Besides, high CCI was an independent risk factor for higher ICU Admission (aOR: 5.91, 95% CI: 2.31-15.08, p < 0.001), hypoglycemia (aOR: 2.19, 95% CI:1.01-4.08, p = 0.049), longer LOS (aOR: 1.23, 95% CI: 1.19-2.27, p = 0.021), and higher hospitalisation expense (aOR: 2089.97, 95% CI: 193.33-3988.61, p = 0.031) of HC patients.

CONCLUSION

CCI is associated with in-hospital mortality, ICU admission, hypoglycemia, LOS, and hospitalisation expense of HC patients. CCI could be an ideal indicator to identify, monitor, and manage chronic comorbidities among HC patients.

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.

Incidence and predictors of mortality in children with diabetic ketoacidosis in the comprehensive specialized referral hospitals of West Amhara Region, Northwest Ethiopia: a retrospective follow-up study

Background

Diabetic ketoacidosis is one of the major life-threatening conditions associated with acute metabolic complications. It remains a major public health problem in developing countries such as Ethiopia.

Objective

To assess the incidence and prediction of mortality in children with diabetic ketoacidosis in West Amhara Region Comprehensive Specialized Referral Hospitals, Northwest Ethiopia, in 2022.

Methods

An institution-based retrospective follow-up study was conducted among 423 study participants with a confirmed diagnosis of diabetic ketoacidosis from 01/01/2017 to 31/12/2021. Data were entered, coded, cleaned, and checked using Epi-Data version 4.6 and exported to Stata version 14 for data analysis.

Results

A total of 401 child records were included in the final analysis and were followed for 3781 days during the study period. The overall mortality of children with diabetic ketoacidosis was 10.6 per 1000 person-days observed (95% CI: 7.8-14.4) during the entire follow-up period. Hypoglycemia (AHR=4.6; 95% CI: 2.13-10.1), rural residence (AHR=2.9; 95% CI=1.01-8.11), age younger than five (AHR=4.4; 95% CI=1.4-13.7) or between five and 10 (AHR=3.1; 95% CI=1.1-8.8), and female gender (AHR=2.6; 95% CI=1.1-5.8) were significant predictors of mortality.

Conclusions

The incidence rate of mortality in children with diabetic ketoacidosis was relatively high. Age, rural residence, female gender, and hypoglycemia were significantly predictive of mortality. Community education or mass campaigns about the signs and symptoms of diabetic ketoacidosis may reduce the mortality rate in children.

Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome in Companion Animals

Diabetes mellitus is a common endocrinopathy in dogs and cats. Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening complications of diabetes resulting from an imbalance between insulin and the glucose counter-regulatory hormones. The first part of this review focuses on the pathophysiology of DKA and HHS, and rarer complications such as euglycemic DKA and hyperosmolar DKA. The second part of this review focuses on the diagnosis and treatment of these complications.

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.

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.

Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis

Objectives

To study the clinical profile and risk factors of cerebral edema and acute kidney injury in children with diabetic ketoacidosis.

Design

Retrospective review of medical records.

Patients

Fifty consecutive patients (age <18 years) admitted to our pediatric intensive care unit with a diagnosis of diabetic ketoacidosis over 5 years.

Materials and methods

Retrospective analysis of medical records was done, and data including patients’ age, sex, presenting features, biochemical profile including blood glucose, osmolality, urea, creatinine, and venous blood gas, electrolytes were recorded at admission, at 12 and 24 hours. Treatment details including fluid administration, rate of fall of glucose, time to resolution of diabetic ketoacidosis were noted. Complications such as cerebral edema and acute kidney injury were recorded. Patients with and without cerebral edema and acute kidney injury were compared. Variables that were significant on univariate analysis were entered in a multiple logistic regression analysis to determine the independent predictors for cerebral edema and acute kidney injury. Odds ratio and 95% confidence interval were calculated using SPSS version 22.

Measurements and main results

Between November 2015 and 2020, 48 patients were admitted for a total of 50 episodes of diabetic ketoacidosis. Two patients had recurrent diabetic ketoacidosis. Median age was 9.5 years (range 1–17). Thirty-one patients (62%) had new-onset type I diabetes mellitus. Twenty-two patients (44%) presented with severe diabetic ketoacidosis. Cerebral edema and acute kidney injury were seen in 11 (22%) and 15 (30%) patients, respectively. On multiple logistic regression analysis, higher blood urea level, lower serum bicarbonate level, and higher corrected sodium levels at admission were identified to be variables independently associated with risk of cerebral edema.

Conclusions

Higher corrected sodium, higher urea level, and lower serum bicarbonate levels at admission are predictive of cerebral edema in patients presenting with diabetic ketoacidosis. The severity of dehydration and acidosis in DKA appears to be a common factor responsible for the development of dysfunction of both brain and kidney.

How to cite this article

Raghunathan V, Jevalikar G, Dhaliwal M, Singh D, Sethi SK, Kaur P, et al. Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian J Crit Care Med 2021;25(12):1446–1451.

Diabetic ketoacidosis (DKA) induced cerebral edema complicating small chronic subdural hematoma/hygroma/ at Zewuditu memorial hospital: a case report

BACKGROUND

While both DKA & CSDH/subdural hygroma/ are known to cause significant morbidity and mortality, there is no a study that shows the role & effect of DKA on CSDH/subdural hygroma/ & vice versa to authors' best knowledge; hence this work will show how important relation does exist between DKA & CSDH/ hygroma. This study highlights the diagnostic & management challenges seen for a case of a 44 years old female black Ethiopian woman admitted with a diagnosis of newly diagnosed type 1 DM with DKA + small CSDH/subdural hygroma/ after she presented with sever global headache and a 3 month history of lost to her work. She needed burrhole & evacuation for complete clinical improvement besides DKA's medical treatment.

CONCLUSION

DKA induced cerebral edema on the CSDH/subdural hematoma/ can have a role in altering any of the parameters (except the thickness of CSDH) for surgical indication of patients with a diagnosis of both CSDH +DM with DKA. Hence, the treating physicians should be vigilant of different parameters that suggests tight brain &/ cerebral edema (including midline shift, the status of cisterns, fissures & sulci) and should not be deceived of the thickness of the CSDH/subdural hygroma/alone; especially when there is a disproportionately tight brain for the degree of collection. Whether DKA induced cerebral edema causes a subdural hygroma is unknown and needs further study.

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.

Outcomes of Children and Adolescents Admitted with Diabetic Ketoacidosis at Kenyatta National Hospital (KNH), Kenya

BACKGROUND

Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication that mainly occurs in patients with type 1 diabetes mellitus and is the foremost cause of death in these children. Overall mortality in children with DKA varies from 3.4% to 13.4% in developing countries. There is a need to understand outcomes among children with DKA in sub-Saharan African countries.

OBJECTIVE

To determine the death rate and clinical outcomes of children and adolescents aged 0-18 years managed for DKA at Kenyatta National Hospital (KNH). Study Methods. This was a retrospective study carried out among children aged 0-18 years admitted with DKA at KNH between February 2013 and February 2018. The study site was the central records department at KNH. The inclusion criteria were children aged 0-18 years admitted with a diagnosis of DKA based on the ISPAD guidelines biochemical criteria.

RESULTS

Out of the 159 files reviewed, the median age of children was 13 years (IQR 10-15). 41.1% of patients had severe DKA while 35.7% had moderate DKA. We reported a mortality of 6.9% while 93.1% of children recovered and were discharged home. The median duration of hospital stay was 8 days. High risk of mortality was reported among children who had high serum creatinine (OR 5.8 (95% CI 1.6-21.2)), decreased urine output (OR 9.0 (95% CI 2.2-37.3)), and altered level of consciousness (OR 5.2 (95% CI 1.1-25.1)).

CONCLUSION

DKA-associated mortality in our study was low at 6.9%. High serum creatinine, decreased urine output, and altered level of consciousness were associated with a significantly higher risk of mortality.

A randomized controlled trial of one bag vs. two bag system of fluid delivery in children with diabetic ketoacidosis: Experience from a developing country

PURPOSE

To compare one vs. two bag system with respect to blood glucose variability (BGV), time for resolution of acidosis and incidence of hypoglycemia, hypokalemia, and cerebral edema in children with diabetic ketoacidosis (DKA).

MATERIAL AND METHODS

In an open labelled randomized controlled trial, thirty consecutive patients ≤12years with DKA were randomized to either one (n=15) or two bag (n=15) system of intravenous fluid delivery. The two bags had similar electrolyte but differing dextrose concentration (none vs. 12.5%) and changing the rate of fluid, delivered different dextrose concentrations. BGV was primary outcome while hypoglycemia (blood glucose, BG<50mg/dL), hypokalemia (serum potassium<3.5mEq/L), time to resolution of acidosis and cerebral edema were secondary outcomes.

RESULTS

The one and two bag systems had similar BGV parameters; median hourly absolute BG change (mg/dL) [44 (30-74.5) vs. 36 (31-49); p=0.54], mean of standard deviation of BG measurements [65.1 (25.1) vs. 65.5 (26.8); p=0.96] and median number of undesirable events (hourly blood sugar change ≥50mg/dL) [4.5 (1.75-6.0) vs. 5.0 (3.0-8.0); p=0.31]. The incidence of hypoglycemia [42.9% (n=6) vs. 26.7% (n=4); p=0.45] and hypokalemia [64% (n=9) vs. 67% (n=10); p=0.23], and mean (SD) time to resolution of acidosis [20.3 (14.8) and 20.3 (7.0); p=0.59] were similar in both the groups. None had cerebral edema.

CONCLUSIONS

The one and two bag systems were similar to each other with respect to BGV, incidence of complications and time to resolution of acidosis.

Root Cause Analysis of Diabetic Ketoacidosis Admissions at a Tertiary Referral Pediatric Emergency Department in North India

OBJECTIVES

To identify system-based factors contributing to Emergency Department (ED) admissions of children with diabetic ketoacidosis (DKA) and related complications with emphasis on parental and physician awareness and prereferral management.

MATERIALS AND METHODS

A prospective observational root cause analysis study of all consecutive admissions of children with DKA to pediatric ED of a tertiary care referral hospital in northern India over a period of 1 year (July 2010-June 2011). Prehospital, health-care system, referral, follow-up, and continuum of care related details were obtained through direct interview of parents and physicians and/or field observations for all enrolled children.

RESULTS

Of the 30 children enrolled, 26 (86.6%) were referrals; 16 (61.5%) from first, 7 (26.9%) from second, and 3 (11.5%) from third health-care facility. More than half (n [%], 18 [60%]) had new onset diabetes and belonged to lower socioeconomic strata. Twenty-two (73.3%) were complicated DKA; shock (n [%], 19 [63%]), hypokalemia (n [%], 11 [36%]), and CE (n [%], 3 [10%]) were the most common complications. Most parents were ignorant of diabetes, its symptoms or complicating DKA. Nearly, half of the cases remained undiagnosed (n = 11) at first contact health-care facility; more so for new onset as compared to known diabetes (9/18 vs. 2/8; P = 0.022). The referring hospitals had limited facilities for rapid blood glucose estimation (n [%], 12 [40%]), blood gas analysis (n [%], 6 [20%]) and insulin infusion. On univariate analysis, patients with missed/delayed diagnosis more often had severe and complicated DKA.

CONCLUSION

Parental ignorance, lower socioeconomic status, lack of clinical experience, and limited primary health-care facilities were root causes for severe and complicated DKA.

Diabetic ketoacidosis in a pediatric intensive care unit

OBJECTIVE

To describe the characteristics of children aged 0-14 years diagnosed with diabetic ketoacidosis and compare the following outcomes between children with prior diagnosis of type 1 diabetes mellitus and children without prior diagnosis of type 1 diabetes mellitus length of hospital stay, severity on admission, insulin dosage, time of continuous insulin use, volume of fluids infused during treatment, and complications.

METHODS

A retrospective descriptive study with review of medical records of patients admitted to the pediatric intensive care unit of a referral hospital from June 2013 to July 2015. The following data regarding 52 admissions were analyzed: age, sex, weight, body surface area, signs, symptoms and severity on admission, blood gas, blood glucose, glycated hemoglobin, serum osmolarity, and index of mortality. The insulin dosage, time of continuous insulin use, volume administered in the expansion phase and in the first 24h, length of stay, and complications such as electrolyte disturbances, hypoglycemia, cerebral edema, and death were compared between the two groups.

RESULTS

Patients without a previous diagnosis of DM1 were younger at admission, with mean age of 8.4 years (p<0.01), reported more nausea or vomiting, polydipsia and polyuria, and showed more weight loss (p<0.01). This study also observed a higher prevalence of hypokalemia (p<0.01) and longer hospital stay in this group.

CONCLUSIONS

No differences in severity between groups were observed. The study showed that children without prior diagnosis of type 1 diabetes mellitus were younger at admission, had more hypokalemia during the course of treatment, and had greater length of hospital stay.

Acute Respiratory Distress Syndrome: A Rare Complication in Pediatric Diabetic Ketoacidosis

Cerebral edema (CE) and non cardiogenic pulmonary edema (acute respiratory distress syndrome, ARDS) are life-threatening complications of diabetic ketoacidosis (DKA). In contrast to CE complicating DKA, which is primarily reported in pediatric patients, ARDS is rarely described in this age group. Here, the authors present a child with DKA who developed both cerebral edema and ARDS during the course of her management. It is feasible that severe acidosis, hypotension, azotemia, hypoalbuminemia and the superimposed aggressive intravenous fluid administration were important risk factors for the development of cerebral edema and ARDS in the index patient. The report highlights the importance of early diagnosis and aggressive therapy in the management of ARDS, and summarizes the published literature on this rarely reported complication of pediatric DKA.

Retrospective comparison of early- versus late-insulin therapy regarding effect on time to resolution of diabetic ketosis and ketoacidosis in dogs and cats: 60 cases (2003-2013)

OBJECTIVE

To determine whether early insulin administration (≤6 h after admission) results in more rapid resolution of diabetic ketosis (DK) and ketoacidosis (DKA), shorter duration of hospitalization, and higher incidence of complications, and whether more severe ketonuria is associated with longer time to resolution of DK/DKA.

DESIGN

Retrospective study (January 1, 2003-March 1, 2013).

SETTING

University teaching hospital.

ANIMALS

Sixty dogs and cats with DK or DKA receiving short-acting insulin therapy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed and data recorded including signalment; previous history of diabetes; intake temperature, blood pressure, blood glucose, pH, base excess, and degree of ketonuria; time to short-acting insulin therapy and resolution of DK/DKA; length of hospitalization; and complications. Insulin was initiated ≤6 hours in the early group and >6 hours in the late group after hospital admission. Early group patients had more rapid resolution of DK/DKA after starting short-acting insulin therapy (36.4 ± 22.6 vs. 55.4 ± 26.6 h, P = 0.014). There was no difference in duration of hospitalization or complications. More severe ketonuria resulted in longer time to resolution of DK/DKA after initiation of short-acting insulin (severe: 50.9 ± 24.2; moderate: 29.6 ± 19; mild: 23.4 ± 21.9 h, P = 0.005, all individual pairwise comparisons P < 0.05).

CONCLUSIONS

Early insulin administration is associated with more rapid resolution of DK/DKA without an associated increase in complication rates. DK/DKA took longer to resolve with more severe ketonuria. Prospective studies are warranted to identify specific time targets for insulin administration in DK/DKA patients.

Severe Ketoacidosis (pH ≤ 6.9) in Type 2 Diabetes: More Frequent and Less Ominous Than Previously Thought

Diabetic ketoacidosis is a life-threatening acute metabolic complication of uncontrolled diabetes. Severe cases of DKA (pH ≤ 7.00, bicarbonate level ≤ 10.0, anion gap > 12, positive ketones, and altered mental status) are commonly encountered in patients with type 1 diabetes and are thought to carry an ominous prognosis. There is not enough information on the clinical course of severely acidotic type 2 diabetes (pH ≤ 6.9) patients with DKA, possibly because this condition is rarely seen in developed countries. In this series, we present 18 patients with type 2 diabetes, DKA, and a pH ≤ 6.9 that presented to a tertiary university hospital over the past 11 years. The objective was to describe their clinical characteristics, the triggering cause, and emphasis on treatment, evolution, and outcomes. The majority of the patients were female (61%). Mean age was 40.66 years (23–59). The patients had been first diagnosed with type 2 diabetes on average 5.27 ± 3.12 years before admission. Glutamic acid decarboxylase (GAD65) antibodies were negative in all patients. The origin of DKA could be attributed to two main causes: treatment omission in 8 (44.4%) patients and infections in 7 (38.8%) patients. The most common symptoms described were general malaise, dyspnea, altered mental status, and abdominal pain. Mean serum glucose on admission was 613.8 ± 114.5 mg/dL. Mean venous pH was 6.84 ± 0.03 with an anion gap of 30.3 ± 2.9 and a venous HCO₃ level of 3.62 ± 1.35 mmol/L. All patients had acute renal failure on admission, with a mean serum creatinine of 1.57 ± 0.35 mg/dL compared to 0.55 ± 0.21 mg/dL at discharge. All patients received regular insulin infusion, aggressive fluid repletion, and 12 patients (66%) received bicarbonate infusion. Mean total insulin infusion dose was 181.7 ± 90.4 U (on average 0.14 ± 0.05 U/Kg/h). Mean time on infusion was 24.4 ± 12.6 hours. We recorded no mortality in this case series. Mean in-hospital stay was 5.0 ± 4.1 days. In conclusion, very severe DKA in type 2 diabetes is not uncommon in our population, shares many features with non-very-severe cases of DKA (bicarbonate therapy did not make a difference in mortality), and can be managed following standard published or institutional guidelines.

Clinical spectrum and outcome of invasive filamentous fungal infections in children with Type 1 diabetes: North Indian experience

There is scarcity of data on spectrum and outcome of invasive filamentous fungal infections (IFIs) in children with Type 1 diabetes (T1D) from developing countries. A retrospective review of medical records of children with T1D hospitalized with IFI over the past decade at the Pediatric Endocrinology and Diabetes Unit of a large tertiary care hospital of North India was performed with an aim to study their clinical spectrum, hospital course and final outcome. Of the 10 patients studied, nasal/paranasal involvement was seen in 6 and pulmonary involvement in 5 patients. One patient developed disseminated disease. Majority of the identified mycoses belonged to Class Zygomycetes Order Mucorales. Early surgery along with antifungal therapy helped limit the extension of infection and achieve a good outcome in majority of patients. Two patients died; one with a late diagnosis of pulmonary mucormycosis and the other with disseminated disease. The longterm morbidity in the survivors was minimal. In conclusion, rapid diagnosis followed by a multimodal approach involving aggressive surgical debridement, appropriate antifungal therapy and control of hyperglycemic state is the key to good outcome in this otherwise lethal infection.

Risk factors for mortality in children with diabetic keto acidosis from developing countries

Diabetic keto acidosis (DKA) is the major cause for mortality in children with Diabetes mellitus (DM). With increasing incidence of type 1 DM worldwide, there is an absolute increase of DM among children between 0-14 year age group and overall incidence among less than 30 years remain the same. This shift towards younger age group is more of concern especially in developing countries where mortality in DKA is alarmingly high. Prior to the era of insulin, DKA was associated with 100% mortality and subsequently mortality rates have come down and is now, 0.15%-0.31% in developed countries. However the scenario in developing countries like India, Pakistan, and Bangladesh are very different and mortality is still high in children with DKA. Prospective studies on DKA in children are lacking in developing countries. Literature on DKA related mortality are based on retrospective studies and are very recent from countries like India, Pakistan and Bangladesh. There exists an urgent need to understand the differences between developed and developing countries with respect to mortality rates and factors associated with increased mortality in children with DKA. Higher mortality rates, increased incidence of cerebral edema, sepsis, shock and renal failure have been identified among DKA in children from developing countries. Root cause for all these complications and increased mortality in DKA could be delayed diagnosis in children from developing countries. This necessitates creating awareness among parents, public and physicians by health education to identify symptoms of DM/DKA in children, in order to decrease mortality in DKA. Based on past experience in Parma, Italy it is possible to prevent occurrence of DKA both in new onset DM and in children with established DM, by simple interventions to increase awareness among public and physicians.

Predictors of altered sensorium at admission in children with diabetic ketoacidosis

OBJECTIVE

To predict factors causing altered sensorium at admission in children with diabetic ketoacidosis (DKA).

METHODS

This retrospective study was done on 139 children with DKA who presented to Pediatric Emergency of a tertiary care hospital between January 2008 and November 2012. The case records were reviewed and information regarding personal details, clinical features, biochemical parameters and outcome was recorded. Statistical analyses were performed in small STATA version 12. Variables associated with altered sensorium in bivariate analysis (P < 0.05) were selected for inclusion in the multivariable logistic regression model.

RESULTS

Mean age was 8.04 ± 4.1 y; Male: Female ratio 0.75:1. The newly diagnosed diabetics were 54.6 % whereas rest were known diabetics. Eighty one percent children in severe DKA, 63 % moderate DKA and 18 % mild DKA had altered sensorium at admission. Univariate analysis revealed significant P values (P < 0.05) for pH and degree of dehydration. Results of final multivariate logistic regression revealed significant P values for pH (for pH 7.1-7.2, AOR-5.47, 95 % CI-1.24-24.1, P = 0.025 and for pH <7.1, AOR-14.19, 95 % CI - 4.13-48.7, P = 0.001) using pH >7.2 as the reference category.

CONCLUSIONS

Alteration in sensorium in children at initial admission with DKA is associated to low blood pH. ROC curve suggested good discrimination of pH for prediction of altered sensorium. The exact pathophysiologic mechanism of how low pH alters sensorium in DKA is still unknown and requires further studies.

Extrapontine myelinolysis in an 18-month-old boy with diabetic ketoacidosis: case report and literature review

Extrapontine myelinolysis is characterized by symmetric demyelination following rapid shifts in serum osmolality in the supratentorial compartment. Extrapontine myelinolysis in children is rare compared to adults. The most common underlying pathophysiology is rapid correction of hyponatremia. Only 2 cases were published after diabetic ketoacidosis without electrolyte imbalance in the English literature. This study presents an unusual and possibly the youngest case of extrapontine myelinolysis that occurred in the setting of diabetic ketoacidosis and complicated cerebral edema without electrolyte imbalance, along with a review of the literature.