wmplLtated br sel'cre CE :md 69 episodes of unwmplLcated DKA was ... durmg tfeatment for DKA I lead computed tOilIograills and their repons wcre revicwed.
Cl i nical Ca re / Education / Nutrition ORIGINAL
ARTICLE
Cerebral Edema in Childhood Diabetic Ketoacidosis Nalural hislOlY, radiographic findin gs, and early identification AI'DIII II' B_ I\1 U I ~ . .111) 1 Ro-.rMl) G _ Q t.: I ~ I.I 'C.. Mill
OBJECTIVE - Children who del"elup lt~rehr:11 edema (eEl durmg dlabclll kClo.leidosl5 (DKA) e)(hlbu dchn~hlc Slgn~ ~nd symplC of adults ( 17.10). Il ypoxta IS funhe r Irnphcaled because the brmns of pallel\ls wlIh OKA 1ll:L}' extract blood ox),gen k ss efrlClently than health y mdlviduals (16) and the reponed association of symptomatic CE with low parti al pressures of carbon diOXide 111 artenal blood Illay rellect hamlful cerebral vasoconstriction (5,6). Exuberant rehydra tion with h}'pototlle lIU1d and bicarbonate ad mIni st rati on m:Ly :Lggra\':Lte the C E (5.6.9,1 1,12,19-22): however, the cvide nce that CE is primarily iatrogel1lc is 1101 compelling (6,8.23-29) . In the absence of an undefSta ndtng of thc pathogenes iS of CE and LIS pre\'e nti ol1, emphasis must be on earl}" reeogmllon of the disease to permit qUick mterwnl1o n . with Ihe hope of re d uclllg mo rbidity and mOrl:lI IlY (4 .8-10)
RESEARCH DE SIGH AND
METHODS -
T he College of Med Icine InstlIul10nal Renew Board gr:lllled an exempILon fo r wntlel1 consent. lI\e(hcal records of 24 prevlousl), unre portcd paILents (ages 1- 15 years) who h:Ld CE during t reatment of OKA at va rious hospItals in the U.S. were reviewed . All patients had poor o.Ulcomes, and the records were o rigmall}' acqUired between 1990 and 1999 for an:ll)'sls dunng hugatlOn. Two pallents who. wcre seen for C E durtng treatment of OKA at our Itlst Ulitlon, " h ~ ll d~ Hospu:l1. were also included. The Shands Ho.spnal database for 1990-1999 Identified 69 COI1SCCULLVe episodes of uncomphcaled OK,\ III 58 child ren who had an eptsode before age 13 rears. Recurrent epIsodes (n = I I) proVided coml).1r:lLLve data for CE case subjects up 10 age 15 years. The dl:lgnos ls of OKA required a cl inical hIstory co.nslstcnt with (habetcs, a l'tnous or arterial pl l 80 rngldl on" u n ne test strip C E was d 13gnoscd whe n a pallent beLllg
154 1
Cerebral edema in DKA
T able I -Bcd~ idc em lumio u of ue um logiCfll 51ti1 C of dli le/ re u wil h DKA
Dlagnosllc critena Abnormal mOtOr or verbal response 10 pam Deeoruca\e or d~cnebrate posture Cranial nerve palsy (especially 111. IV. and VI) t\bnormal neurogenic respiratOry pattern (e.g .. grunlmg.I:lchypn~a. Cherne-SlOkes resplwilon. apneusIs) MlJor cTIlena Ahered mentallon/fluctuatmg Iel'eI of consciousness Suslamcd heart rate deceleration (dC'chne more than 20 bpm) nOI allnbUlablc 10 llllprol'cd Intravascular \"olume or slecp Slatc AgC-1Il3ppropTlau~ Incontinence Mmor enttria VOlllltmg Headache Lethargy or hemg nOI casllr aroused from sleep Diastolic blood pressure >90 mmHg f\ge 20 bprn) had to be of sudden onset, persistent (recorded in the nursing reco rd on :It leaSt twO stlccessive entries th:lt were separated by at le:lst 15 mm), :md unre· lated to slee p or rapid fluid replacement. Hea rt rlte did not haw to be truly br:ldycardiac (i.e"
