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

Soto-Rivera CL, Asaro LA, Agus MS, DeCourcey DD. Suspected Cerebral Edema in Diabetic Ketoacidosis: Is There Still a Role for Head CT in Treatment Decisions?  Pediatr Crit Care Med. 2017 Jan 19. [Epub ahead of print]

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.


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.

Use of serum bicarbonate to substitute for venous pH in new-onset diabetes. (Emrath)

von Oettingen J, Wolfsdorf J, Feldman HA, et al. Use of serum bicarbonate to substitute for venous pH in new-onset diabetes. Pediatrics. 2015 Aug;136(2):e371-7.

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OBJECTIVE: To investigate whether serum bicarbonate (HCO3) levels can be used to accurately diagnose diabetic ketoacidosis (DKA) and classify its severity in children with new-onset diabetes mellitus (NODM).

METHODS: Retrospective study of all patients with NODM presenting to Boston Children’s Hospital from October 1, 2007, to July 1, 2013. DKA was defined as blood glucose ≥200 mg/dL, venous pH (vpH) <7.3, and urine ketones ≥2+, and severe DKA as vpH <7.1. Linear regression was used to assess serum HCO3 as a predictor of vpH, and logistic regression to evaluate serum HCO3 as a predictor of DKA and severe DKA.

RESULTS: Of 690 study cohort subjects (47% girls, age 10.8 ± 4.3 years, 76.7% white), 19.4% presented with DKA. The relationship between serum HCO3 and vpH was log-linear (r = 0.87, 95% CI 0.85-0.89, P < .001). HCO3 predicted vpH (R(2) 0.75, P < .001) using the formula vpH = 6.81301 + (0.17823*ln[HCO3]) and DKA and severe DKA (c-statistic 0.97 [95% CI 0.96-0.99, P < .001] and 0.99 [95% CI 0.991-0.999, P < .001], respectively). HCO3 cutoffs of <18 and <8 mmol/L had sensitivities of 91.8% and 95.2%, and specificities of 91.7% and 96.7%, respectively, to diagnose DKA and severe DKA. Findings were similar in a validation cohort of 197 subjects.

CONCLUSIONS: Serum HCO3 concentration alone can substitute for vpH to diagnose DKA and classify severity in children with NODM. It is suggested as an alternative to reliance on vpH, especially in settings in which access to vpH measurement is limited.

Effect of normal saline and half normal saline on serum electrolytes during recovery phase of diabetic ketoacidosis. (Stockwell)

Basnet S, Venepalli PK, Andoh J, Verhulst S, Koirala J. Effect of normal saline and half normal saline on serum electrolytes during recovery phase of diabetic ketoacidosis. J Intensive Care Med. 2014 Jan-Feb;29(1):38-42.

Objective: This study aims to describe the effect of 0.9% saline (NS) versus 0.45% saline (half NS) when used during recovery phase of diabetic ketoacidosis (DKA) in children.

Methods: A retrospective analysis of all children (1-18 years old) with DKA admitted in the pediatric intensive care unit (PICU) from 2005 to 2009 was undertaken. The primary end point was effect on serum electrolytes and acidosis.

Results: Compared to 47 patients who received only NS (group A) throughout the recovery period and 33 patients who received NS but were switched to half NS (group B) at some point during recovery, 41 who received only half NS (group C) had a significant decrease in corrected serum sodium (P < .01). Hyperchloremia leading to nonanion gap acidosis was significantly greater in NS groups A and B than in half NS group C (P < .01). This led to increased duration of insulin infusion and length of stay in the PICU in the NS groups.

Conclusions: Hyperchloremia resulting in nonanion gap acidosis can occur and may prolong the duration of insulin infusion and length of PICU stay in patients receiving NS as post-bolus rehydration fluid. Alternatively, the use of half NS may result in a decrease in serum-corrected sodium. Providers need to be vigilant toward this while using higher or lower sodium chloride when managing children with DKA. Larger trials are required to study the clinical significance of the results of this study.

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Increasing use of hypertonic saline over mannitol in the treatment of symptomatic cerebral edema in pediatric diabetic ketoacidosis: an 11-year retrospective analysis of mortality. (Dugan)

Decourcey DD, Steil GM, Wypij D, Agus MS. Increasing Use of Hypertonic Saline Over Mannitol in the Treatment of Symptomatic Cerebral Edema in Pediatric Diabetic Ketoacidosis: An 11-Year Retrospective Analysis of Mortality. Pediatr Crit Care Med. 2013 Jul 16. [Epub ahead of print]

OBJECTIVES: Cerebral edema in diabetic ketoacidosis is a devastating complication with significant morbidity and mortality. This entity has traditionally been treated with mannitol, but use of 3% hypertonic saline has become an accepted alternative. We sought to assess if changes in the use of hyperosmolar therapies for treatment of cerebral edema in diabetic ketoacidosis may have influenced mortality over the last decade.

DESIGN: Retrospective cohort study.

SETTING: Patients discharged between 1999 and 2009 from 41 children’s hospitals that provided data to the Pediatric Health Information System database.

PATIENTS: A total of 43,107 children (age < 19) with diagnosis codes related to diabetic ketoacidosis were identified and further classified as having cerebral edema if treated with mannitol and/or 3% hypertonic saline.


MEASUREMENTS AND MAIN RESULTS: Billing for 3% hypertonic saline and mannitol was quantified, and mortality associated with both diabetic ketoacidosis and cerebral edema in diabetic ketoacidosis was examined. Overall mortality in diabetic ketoacidosis was 0.25% and significantly decreased (p < 0.001) over the study period, whereas the frequency of treatment with hyperosmolar agents (3.8%) was unchanged. Use of mannitol as a sole agent decreased from 98% to 49%, 3% hypertonic saline as a sole agent increased from 2% to 39%, and combined therapy increased from 0% to 10%. Use of 3% hypertonic saline alone was associated with a higher mortality than mannitol alone (adjusted odds ratio, 2.71 [95% CI, 1.01-7.26]) in patients treated for cerebral edema. Similar results were obtained after adjustment for the propensity to receive hypertonic saline (adjusted odds ratio, 2.33 [95% CI, 1.07-5.07]) and in the subset of subjects receiving mechanical ventilation (adjusted odds ratio, 3.27 [95% CI, 1.12-9.60]).

CONCLUSION: Hypertonic saline has replaced mannitol as the most commonly used agent at many institutions for treatment of cerebral edema in diabetic ketoacidosis. In our analysis, however, use of hypertonic saline as a sole agent was associated with an increased risk of mortality. Recognizing the limitations of administrative data, we conclude that equipoise regarding choice of therapy for treatment of cerebral edema in diabetic ketoacidosis should be maintained until a more definitive study is performed to guide therapy of this potentially lethal complication.

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