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Ing TS, Ganta K, Bhave G, Lew SQ, Agaba EI, Argyropoulos C, Tzamaloukas AH. The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications. Front Med (Lausanne) 2020; 7:477. [PMID: 32984372 PMCID: PMC7479837 DOI: 10.3389/fmed.2020.00477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Abstract
In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.
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Affiliation(s)
- Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, United States
| | - Kavitha Ganta
- Medicine Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Gautam Bhave
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susie Q Lew
- Department of Medicine, George Washington University School of Medicine, Washington, DC, United States
| | | | - Christos Argyropoulos
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
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Tran TTT, Pease A, Wood AJ, Zajac JD, Mårtensson J, Bellomo R, Ekinci EI. Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols. Front Endocrinol (Lausanne) 2017; 8:106. [PMID: 28659865 PMCID: PMC5468371 DOI: 10.3389/fendo.2017.00106] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/02/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs). OBJECTIVE To review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes. METHODS Ovid Medline searches were conducted with limits "all adult" and published between "1973 to current" applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers' assessment of title, abstract, and availability. RESULTS A total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over "sliding scale" insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1-2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes. CONCLUSION There are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.
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Affiliation(s)
- Tara T. T. Tran
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Anthony Pease
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Anna J. Wood
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Jeffrey D. Zajac
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Elif I. Ekinci
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
- Menzies School of Health Research, Darwin, NT, Australia
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Cho YM, Park BS, Kang MJ. A case report of hyperosmolar hyperglycemic state in a 7-year-old child: An unusual presentation of first appearance of type 1 diabetes mellitus. Medicine (Baltimore) 2017; 96:e7369. [PMID: 28640151 PMCID: PMC5484263 DOI: 10.1097/md.0000000000007369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE A hyperosmolar hyperglycemic state (HHS) is a rare presentation of a hyperglycemic crisis in children with diabetes mellitus. As this condition can be fatal and has high morbidity, early recognition and proper management are necessary for a better outcome. Here, we report a rare case of HHS as the first presentation of type 1 diabetes mellitus (T1DM) in a 7-year-old girl. PATIENT CONCERNS The patient was admitted due to polyuria and weight loss in the past few days. The initial blood glucose level was 1167mg/dL. DIAGNOSES On the basis of clinical manifestations and laboratory results, she was diagnosed with T1DM and HHS. INTERVENTIONS Treatment was started with intravenous fluid and regular insulin. OUTCOMES She was discharged without any complications related to HHS and is being followed up in the outpatient clinic with split insulin therapy. LESSONS As the incidence of T1DM is increasing, emergency physicians and pediatricians should be aware of HHS to make an early diagnosis for appropriate management, as it can be complicated in young children with T1DM.
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Hoffman WH, Artlett CM, Boodhoo D, Gilliland MGF, Ortiz L, Mulder D, Tjan DHT, Martin A, Tatomir A, Rus H. Markers of immune-mediated inflammation in the brains of young adults and adolescents with type 1 diabetes and fatal diabetic ketoacidosis. Is there a difference? Exp Mol Pathol 2017; 102:505-514. [PMID: 28533125 DOI: 10.1016/j.yexmp.2017.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 12/17/2022]
Abstract
Due to the limited data on diabetic ketoacidosis and brain edema (DKA/BE) in children/adolescents and the lack of recent data on adults with type 1 diabetes (T1D), we addressed the question of whether neuroinflammation was present in the fatal DKA of adults. We performed immunohistochemistry (IHC) studies on the brains of two young adults with T1D and fatal DKA and compared them with two teenagers with poorly controlled diabetes and fatal DKA. C5b-9, the membrane attack complex (MAC) had significantly greater deposits in the grey and white matter of the teenagers than the young adults (p=0.03). CD59, a MAC assembly inhibitory protein was absent, possibly suppressed by the hyperglycemia in the teenagers but was expressed in the young adults despite comparable average levels of hyperglycemia. The receptor for advanced glycation end products (RAGE) had an average expression in the young adults significantly greater than in the teenagers (p=0.02). The autophagy marker Light Chain 3 (LC3) A/B was the predominant form of programmed cell death (PCD) in the teenage brains. The young adults had high expressions of both LC3A/B and TUNEL, an apoptotic cell marker for DNA fragmentation. BE was present in the newly diagnosed young adult with hyperglycemic hyperosmolar DKA and also in the two teenagers. Our data indicate that significant differences in neuroinflammatory components, initiated by the dysregulation of DKA and interrelated metabolic and immunologic milieu, are likely present in the brains of fatal DKA of teenagers when compared with young adults.
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Affiliation(s)
- William H Hoffman
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA 30912, United States.
| | - Carol M Artlett
- Department of Microbiology & Immunology, Drexel University College of Medicine, Philadelphia, PA 19129, United States
| | - Dallas Boodhoo
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Mary G F Gilliland
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, Greenville, NC 27858, United States
| | - Luis Ortiz
- Department of Pediatrics, Nephrology, Medical College of Georgia, Augusta University, Augusta, GA 30912, United States
| | - Dries Mulder
- Department of Pathology, Rijnstate Hospital, Arnhem, The Netherlands
| | - David H T Tjan
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Alvaro Martin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Alexandru Tatomir
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Horea Rus
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Research Service, Veterans Administration Maryland Health Care System, MD 21201, United States.
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Affiliation(s)
- Stuart J Brink
- New England Diabetes and Endocrinology Center (NEDEC), Waltham, MA, USA, and Associate Clinical Professor of Pediatrics; Tufts University School of Medicine; Boston MA USA
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Arora R, Chiwane S, Hartwig E, Kannikeswaran N. A child with altered sensorium, hyperglycemia, and elevated troponins. J Emerg Med 2013; 46:184-90. [PMID: 23880446 DOI: 10.1016/j.jemermed.2013.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 01/23/2013] [Accepted: 05/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially life-threatening complications of diabetes mellitus. Although DKA and HHS share similar features, they are distinct clinical entities requiring different treatment measures. OBJECTIVE This case illustrates that the clinical distinction between these two entities can be difficult at times, especially in children who can present with an overlapping picture. CASE REPORT We report an interesting case of a 12-year-old whose initial presentation of diabetes was a mixed picture of hyperosmolar DKA and HHS coma complicated by myocardial strain and acute renal insufficiency. The myocardial strain resolved completely with resolution of the metabolic abnormalities. CONCLUSIONS Emergency physicians should be cognizant of varied presentations of hyperglycemic emergencies in children to initiate appropriate management for better outcomes.
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Affiliation(s)
- Rajan Arora
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Saurabh Chiwane
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Earl Hartwig
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Chaudhary M, Kamalaksha S, Trainer VJ, Obuobie K, Kalhan A. Acute cerebellar infarction in a young patient presenting with diabetic ketoacidosis. PRACTICAL DIABETES 2012. [DOI: 10.1002/pdi.1726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.
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Abstract
The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.
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Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA,
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Toledo JD, Modesto V, Peinador M, Alvarez P, López-Prats JL, Sanchis R, Vento M. Sodium concentration in rehydration fluids for children with ketoacidotic diabetes: effect on serum sodium concentration. J Pediatr 2009; 154:895-900. [PMID: 19230907 DOI: 10.1016/j.jpeds.2008.12.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Revised: 11/14/2008] [Accepted: 12/23/2008] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To analyze in a retrospective cohort if sodium concentration in the rehydration fluids influence natremia in children with diabetic ketoacidosis (DKA). STUDY DESIGN Consecutive episodes of diabetic ketoacidosis admitted in a tertiary care referral center from 2000 to 2005. Rehydration was programmed for 48 hours with a 2-bag system. Initial rehydration was performed with isotonic fluids and thereafter with variable tonicity. Analysis of the influence of the different factors on natremia was performed with a multivariate linear regression analysis. RESULTS Forty-two episodes of DKA were reviewed. Increased sodium content in rehydration fluids behaved as an independent variable, causing a positive tendency of natremia (P < .008). CONCLUSIONS Sodium concentration in the rehydration fluids behaves as an independent factor that influences positively the trend of the serum concentration of sodium during DKA rehydration. We propose the use of isotonic solutions for rehydration in diabetic ketoacidosis.
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Affiliation(s)
- Juan Diego Toledo
- Pediatric Intensive Care Unit, Children's Hospital La Fe, Valencia, Spain
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Ochola J, Venkatesh B. Rational Approach to Fluid Therapy in Acute Diabetic Ketoacidosis. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE To review the causes of cerebral edema in diabetic ketoacidosis (CEDKA), including pathophysiology, risk factors, and proposed mechanisms, to review the diagnosis, treatment, and prognosis of CEDKA and the treatment of diabetic ketoacidosis as it pertains to prevention of cerebral edema. DATA SOURCE A MEDLINE search using OVID was done through 2006 using the search terms cerebral edema and diabetic ketoacidosis. RESULTS OF SEARCH: There were 191 citations identified, of which 150 were used. An additional 42 references listed in publications thus identified were also reviewed, and two book chapters were used. STUDY SELECTION The citations were reviewed by the author. All citations identified were used except 25 in foreign languages and 16 that were duplicates or had inappropriate titles and/or subject matter. Of the 194 references, there were 21 preclinical and 40 clinical studies, 35 reviews, 15 editorials, 43 case reports, 29 letters, three abstracts, six commentaries, and two book chapters. DATA SYNTHESIS The data are summarized in discussion. CONCLUSIONS The causes and mechanisms of CEDKA are unknown. CEDKA may be due as much to individual biological variance as to severity of underlying metabolic derangement of the child's state and/or treatment risk factors. Treatment recommendations for CEDKA and diabetic ketoacidosis are made taking into consideration possible mechanisms and risk factors but are intended as general guidelines only in view of the absence of conclusive evidence.
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Minimizing the risk of developing cerebral edema during therapy for diabetic ketoacidosis. Crit Care Med 2007. [DOI: 10.1097/01.ccm.0000262944.17294.ff] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The object of this review is to provide the definitions and criteria for diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS), and convey current knowledge of the causes of permanent disability or mortality from complications of these conditions, of the risk factors for DKA and HHS, and of early indicators and contemporary treatment of suspected cerebral edema. The frequency of DKA at onset of type 1 diabetes mellitus (DM1) varies from 10-70%, depending on availability of health care and frequency of diabetes. At the onset of type 2 diabetes (DM2), DKA occurs in 5-52%. One study reported HHS in approximately 4% of new patients with DM2. Recurrent DKA rates are equally dependent on variability in medical services and socio-economic circumstances, and are estimated to be eight episodes per 100 patient years, with 20% of patients accounting for 80% of the episodes. Mortality for each episode of DKA internationally varies from 0.15-0.31%, with idiopathic cerebral edema accounting for two-thirds or more of this mortality. Other causes of death or disability include untreated DKA or HHS, hypokalemia, hypophosphatemia, hypoglycemia, other intracerebral complications, peripheral venous thrombosis, mucormycosis, rhabdomyolysis, acute pancreatitis, acute renal failure, sepsis, aspiration pneumonia, and other pulmonary complications. Population-based studies from the UK, Australia, the USA, and Canada report cerebral edema incidence in DKA of 0.5-2.0%. Published information does not support the notion that treatment factors are causal in cerebral edema. Younger age, greater severity of acidosis, degree of hypocapnia, and severity of dehydration have been suggested as risk factors in several studies. Bimodal distribution of the time of onset of cerebral edema and wide variation in brain imaging findings suggest the variability and likely multiple causation of the clinical picture. Functional brain scanning has indicated that DKA is accompanied by increased cerebral blood flow suggesting that the predominant mechanism of edema formation is a vasogenic process. A method of monitoring for diagnostic and major and minor signs of cerebral edema has been proposed and tested which indicates that intervention will be required in five individuals to provide early intervention for a single case of cerebral edema. The preferred intervention of mannitol infusion has typically been accompanied by intubation and hyperventilation, but recent evidence indicates outcome is adversely affected by aggressive hyperventilation. The prevention of DKA and HHS at the onset of diabetes mellitus requires a high degree of awareness and suspicion by primary care providers; prevention of recurrent DKA necessitates a diligent team effort.
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Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Children's Medical Services Center, 1701 SW 16th Avenue, Gainesville 32608, USA.
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Hiller KM, Wolf SJ. Cerebral edema in an adult patient with diabetic ketoacidosis. Am J Emerg Med 2005; 23:399-400. [PMID: 15915425 DOI: 10.1016/j.ajem.2005.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Affiliation(s)
- Neil H White
- Division of Endocrinology and Metabolism, Department of Pediatrics, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Campus Box 8208, St. Louis, Missouri 63110, USA.
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Current literature in diabetes. Diabetes Metab Res Rev 2003; 19:76-83. [PMID: 12592647 DOI: 10.1002/dmrr.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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