Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Physiologic Management of Diabetic Ketoacidemia: A 5-Year Prospective Pediatric Experience in 231 Episodes

Physiologic Management of Diabetic Ketoacidemia: A 5-Year Prospective Pediatric Experience in 231... Abstract Objective: To determine whether gradual rehydration in moderate and severe diabetic ketoacidemia (DKA) can safely prevent untoward declines in calculated effective osmolality (Eosm) early in treatment and, hence, help prevent major central nervous system complications. Design: Prospective study. Setting: Three tertiary care hospitals. Patients: Two hundred thirty-one consecutive episodes of DKA in 149 patients aged 10 months to 20 years admitted during a 5-year period. Interventions: Insulin therapy in addition to rehydration using an estimated volume of deficit with planned administration over 48 hours; initial administration of rehydration solutions with an osmolality approximating that of the patient; and intensive patient monitoring. Measurements: Mean lowest calculated Eosm (Eosml) during the first 24 hours of treatment; trend of the concentration of sodium in serum in the first 12 hours of treatment; comparison of pretreatment serum concentrations of glucose, urea nitrogen, and corrected sodium between mildly and very severely dehydrated patients; and patient outcome. Results: A mean (±SD) Eosml of 285.8±10.5 mOsm/kg Nater and an increase in the concentration of sodium in serum in 90% of episodes were documented. There were statistically significant differences in serum concentrations of glucose, urea nitrogen, and corrected sodium in mildly vs very severely dehydrated patients. There were no deaths or near-death episodes. Conclusions: Management of moderate and severe DKA with a 48-hour planned rehydration is safe and prevents untoward declines in Eosm. Coupled with intensive monitoring, gradual rehydration can protect against life-threatening increases in intracranial pressure and brain herniation.(Arch Pediatr Adolesc Med. 1994;148:1046-1052) References 1. FitzGerald MG, O'Sullivan DJ, Mallins JM. Fatal diabetic ketosis . BMJ . 1961; 1:247-250.Crossref 2. Young E, Bradley RF. Cerebral edema with irreversible coma in severe diabetic ketoacidosis . N Engl J Med . 1967;276:665-669.Crossref 3. Scibilia J, Feingold D, Dorman J, Becker D, Drash A. Why do children with diabetes die? Acta Endocrinol Suppl . 1986;279:326-333. 4. Levitsky LL, Ekwo E, Goselink CA, Solomon IL, Aceto T. Death from diabetes in hospitalized children (1970-1988) . Pediatr Res . 1991;29:195A. 5. Harris GD, Fiordalisi I, Harris WL, Mosovich LL, Finberg L. Minimizing the risk of brain herniation during treatment of diabetic ketoacidemia: a retrospective and prospective study . J Pediatr . 1990;117:22-31.Crossref 6. Saavedra JM, Harris GD, Li S, Finberg L. Capillary refilling (skin turgor) in the assessment of dehydration . AJDC . 1991;145:296-298. 7. Finberg L, Kravath RE, Hellerstein S. Water and Electrolytes in Pediatrics: Physiology, Pathology and Treatment . 2nd ed. Philadelphia, Pa: WB Saunders Co; 1993:18. 8. Moran SM, Jamison RL. The variable hyponatremic response to hyperglycemia . West J Med . 1985;142:49-53. 9. Katz MA. Hyperglycemia-induced hyponatremia: calculation of expected serum sodium depression . N Engl J Med . 1973;289:843-844.Crossref 10. Hoffman WH, Steinhart CM, El Gammal T, Steele S, Cuardrado AR, Morse KP. Cranial CT in children and adolescents with diabetic ketoacidosis . AJNR Am J Neuroradiol . 1988;9:733-739. 11. Taubin H, Matz R. Cerebral edema, diabetes insipidus, and sudden death during the treatment of diabetic ketoacidosis . Diabetes . 1968;17:108-109. 12. Warren P, Villalutz ES, Rosenberg H. Diabetic ketoacidosis with fatal cerebral edema . Pediatrics . 1969;43:620-622. 13. Rosenbloom AL, Riley WJ, Weber FT, Malone JI, Donnely WH. Cerebral edema complicating diabetic ketoacidosis in childhood . J Pediatr . 1980;96:357-361.Crossref 14. Glasgow AM. Devastating cerebral edema in diabetic ketoacidosis before therapy . Diabetes Care . 1991;14:77-78. 15. DiMaio VJM, Sturner WQ, Coe JI. Sudden and unexpected deaths after the acute onset of diabetes mellitus . J Forensic Sci . 1977;22:147-151. 16. Lien Y-HH, Shapiro J, Chan L. Effects of hypernatremia on organic brain osmoles . J Clin Invest . 1990;85:1427-1435.Crossref 17. Lohr JW, McReynolds J, Grimaldi T, Acara M. Effect of acute and chronic hypernatremia on myoinositol and sorbitol in rat brain and kidney . Life Sci . 1988; 43:271-276.Crossref 18. Trachtman H, Futterweit S, Sturman JA. Cerebral taurine transport is increased during streptozotocin-induced diabetes in rats . Diabetes . 1992;41: 1130-1140.Crossref 19. Trachtman H, Barbour R, Sturman JA, Finberg L. Taurine and osmoregulation: taurine is a cerebral osmoprotective molecule in chronic hypernatremic dehydration . Pediatr Res . 1988;23:35-39.Crossref 20. Trachtman H, Del Pizzo R, Sturman JA, Huxtable RJ, Finberg L. Taurine and osmoregulation, II: administration of taurine analogs affords cerebral osmoprotection during chronic hypernatremic dehydration . AJDC . 1988;142:1194-1198. 21. Harris GD, Lohr JW, Fiordalisi I, Acara M. Brain osmoregulation during extreme and moderate dehydration in a rat model of severe DKA . Life Sci . 1993; 53:185-191.Crossref 22. Durr JA, Hoffman WH, Sklar AH, El Gammal T, Steinhart CM. Correlates of brain edema in uncontrolled IDDM . Diabetes . 1992;41:627-632.Crossref 23. Krane EJ, Rockoff MA, Wallman JK, et al. Subclinical brain swelling in children during treatment of diabetic ketoacidosis . N Engl J Med . 1985;312:1147-1151.Crossref 24. Sutin KM, Ruskin KJ, Kaufman BS. Intravenous fluid therapy in neurologic injury . In: Kaufman BS, ed. Critical Care Clinics: Fluid Resuscitation of the Critically III . Philadelphia, Pa: WB Saunders Co; 1992;8:380-384. 25. Harris GD, Fiordalisi I, Finberg L. Safe management of diabetic ketoacidemia . J Pediatr . 1988;113:65-67.Crossref 26. Harris GD, Fiordalisi I, Finberg L. Minimizing risk of brain herniation during treatment of diabetic ketoacidemia (reply) . J Pediatr . 1990;177:1009-1010.Crossref 27. Aoki BY, McCloskey K. Evaluation, Stabilization, and Transport of the Critically III Child . St Louis, Mo: Mosby–Year Book; 1992:210. 28. Johnson EB, ed. The Harriet Lane Handbook . St Louis, Mo: Mosby–Year Book; 1993:25. 29. Nichols DG, Yaster M, Lappe DG, Buck JR. Golden Hour: The Handbook of Advanced Pediatric Life Support . St Louis, Mo: Mosby–Year Book; 1991:186. 30. Hale DE. Endocrine emergencies . In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine . 3rd ed. Baltimore, Md: Williams & Wilkins; 1993: 940-944. 31. Shefler AG, ed. The HSC Handbook of Pediatrics . 8th ed. St Louis, Mo: Mosby–Year Book; 1992:73-74. 32. Foster DW. Diabetes mellitus . In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . 12th ed. New York, NY: McGraw-Hill International Book Co; 1991:1751-1752. 33. Duck SC, Wyatt DT. Factors associated with brain herniation in the treatment of diabetic ketosis . J Pediatr . 1988;113:10-14.Crossref 34. Laron Z, Karp M. Diabetes mellitus in children and adolescents . In: Bertrand J, Rappoport R, Sizenko PC, eds. Pediatric Endocrinology: Physiology, Pathology and Clinical Aspects . 2nd ed. Baltimore, Md: Williams & Wilkins; 1993:604. 35. Harris GD, Fiordalisi I, Yu C. Intracranial pressure (ICP) during repair of diabetic ketoacidemia (DKA) in a rabbit model: the effect of fluid and electrolyte therapy . Pediatr Res . 1994;35:203A. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Physiologic Management of Diabetic Ketoacidemia: A 5-Year Prospective Pediatric Experience in 231 Episodes

Loading next page...
 
/lp/american-medical-association/physiologic-management-of-diabetic-ketoacidemia-a-5-year-prospective-w43JCO4f9Q
Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpedi.1994.02170100044009
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To determine whether gradual rehydration in moderate and severe diabetic ketoacidemia (DKA) can safely prevent untoward declines in calculated effective osmolality (Eosm) early in treatment and, hence, help prevent major central nervous system complications. Design: Prospective study. Setting: Three tertiary care hospitals. Patients: Two hundred thirty-one consecutive episodes of DKA in 149 patients aged 10 months to 20 years admitted during a 5-year period. Interventions: Insulin therapy in addition to rehydration using an estimated volume of deficit with planned administration over 48 hours; initial administration of rehydration solutions with an osmolality approximating that of the patient; and intensive patient monitoring. Measurements: Mean lowest calculated Eosm (Eosml) during the first 24 hours of treatment; trend of the concentration of sodium in serum in the first 12 hours of treatment; comparison of pretreatment serum concentrations of glucose, urea nitrogen, and corrected sodium between mildly and very severely dehydrated patients; and patient outcome. Results: A mean (±SD) Eosml of 285.8±10.5 mOsm/kg Nater and an increase in the concentration of sodium in serum in 90% of episodes were documented. There were statistically significant differences in serum concentrations of glucose, urea nitrogen, and corrected sodium in mildly vs very severely dehydrated patients. There were no deaths or near-death episodes. Conclusions: Management of moderate and severe DKA with a 48-hour planned rehydration is safe and prevents untoward declines in Eosm. Coupled with intensive monitoring, gradual rehydration can protect against life-threatening increases in intracranial pressure and brain herniation.(Arch Pediatr Adolesc Med. 1994;148:1046-1052) References 1. FitzGerald MG, O'Sullivan DJ, Mallins JM. Fatal diabetic ketosis . BMJ . 1961; 1:247-250.Crossref 2. Young E, Bradley RF. Cerebral edema with irreversible coma in severe diabetic ketoacidosis . N Engl J Med . 1967;276:665-669.Crossref 3. Scibilia J, Feingold D, Dorman J, Becker D, Drash A. Why do children with diabetes die? Acta Endocrinol Suppl . 1986;279:326-333. 4. Levitsky LL, Ekwo E, Goselink CA, Solomon IL, Aceto T. Death from diabetes in hospitalized children (1970-1988) . Pediatr Res . 1991;29:195A. 5. Harris GD, Fiordalisi I, Harris WL, Mosovich LL, Finberg L. Minimizing the risk of brain herniation during treatment of diabetic ketoacidemia: a retrospective and prospective study . J Pediatr . 1990;117:22-31.Crossref 6. Saavedra JM, Harris GD, Li S, Finberg L. Capillary refilling (skin turgor) in the assessment of dehydration . AJDC . 1991;145:296-298. 7. Finberg L, Kravath RE, Hellerstein S. Water and Electrolytes in Pediatrics: Physiology, Pathology and Treatment . 2nd ed. Philadelphia, Pa: WB Saunders Co; 1993:18. 8. Moran SM, Jamison RL. The variable hyponatremic response to hyperglycemia . West J Med . 1985;142:49-53. 9. Katz MA. Hyperglycemia-induced hyponatremia: calculation of expected serum sodium depression . N Engl J Med . 1973;289:843-844.Crossref 10. Hoffman WH, Steinhart CM, El Gammal T, Steele S, Cuardrado AR, Morse KP. Cranial CT in children and adolescents with diabetic ketoacidosis . AJNR Am J Neuroradiol . 1988;9:733-739. 11. Taubin H, Matz R. Cerebral edema, diabetes insipidus, and sudden death during the treatment of diabetic ketoacidosis . Diabetes . 1968;17:108-109. 12. Warren P, Villalutz ES, Rosenberg H. Diabetic ketoacidosis with fatal cerebral edema . Pediatrics . 1969;43:620-622. 13. Rosenbloom AL, Riley WJ, Weber FT, Malone JI, Donnely WH. Cerebral edema complicating diabetic ketoacidosis in childhood . J Pediatr . 1980;96:357-361.Crossref 14. Glasgow AM. Devastating cerebral edema in diabetic ketoacidosis before therapy . Diabetes Care . 1991;14:77-78. 15. DiMaio VJM, Sturner WQ, Coe JI. Sudden and unexpected deaths after the acute onset of diabetes mellitus . J Forensic Sci . 1977;22:147-151. 16. Lien Y-HH, Shapiro J, Chan L. Effects of hypernatremia on organic brain osmoles . J Clin Invest . 1990;85:1427-1435.Crossref 17. Lohr JW, McReynolds J, Grimaldi T, Acara M. Effect of acute and chronic hypernatremia on myoinositol and sorbitol in rat brain and kidney . Life Sci . 1988; 43:271-276.Crossref 18. Trachtman H, Futterweit S, Sturman JA. Cerebral taurine transport is increased during streptozotocin-induced diabetes in rats . Diabetes . 1992;41: 1130-1140.Crossref 19. Trachtman H, Barbour R, Sturman JA, Finberg L. Taurine and osmoregulation: taurine is a cerebral osmoprotective molecule in chronic hypernatremic dehydration . Pediatr Res . 1988;23:35-39.Crossref 20. Trachtman H, Del Pizzo R, Sturman JA, Huxtable RJ, Finberg L. Taurine and osmoregulation, II: administration of taurine analogs affords cerebral osmoprotection during chronic hypernatremic dehydration . AJDC . 1988;142:1194-1198. 21. Harris GD, Lohr JW, Fiordalisi I, Acara M. Brain osmoregulation during extreme and moderate dehydration in a rat model of severe DKA . Life Sci . 1993; 53:185-191.Crossref 22. Durr JA, Hoffman WH, Sklar AH, El Gammal T, Steinhart CM. Correlates of brain edema in uncontrolled IDDM . Diabetes . 1992;41:627-632.Crossref 23. Krane EJ, Rockoff MA, Wallman JK, et al. Subclinical brain swelling in children during treatment of diabetic ketoacidosis . N Engl J Med . 1985;312:1147-1151.Crossref 24. Sutin KM, Ruskin KJ, Kaufman BS. Intravenous fluid therapy in neurologic injury . In: Kaufman BS, ed. Critical Care Clinics: Fluid Resuscitation of the Critically III . Philadelphia, Pa: WB Saunders Co; 1992;8:380-384. 25. Harris GD, Fiordalisi I, Finberg L. Safe management of diabetic ketoacidemia . J Pediatr . 1988;113:65-67.Crossref 26. Harris GD, Fiordalisi I, Finberg L. Minimizing risk of brain herniation during treatment of diabetic ketoacidemia (reply) . J Pediatr . 1990;177:1009-1010.Crossref 27. Aoki BY, McCloskey K. Evaluation, Stabilization, and Transport of the Critically III Child . St Louis, Mo: Mosby–Year Book; 1992:210. 28. Johnson EB, ed. The Harriet Lane Handbook . St Louis, Mo: Mosby–Year Book; 1993:25. 29. Nichols DG, Yaster M, Lappe DG, Buck JR. Golden Hour: The Handbook of Advanced Pediatric Life Support . St Louis, Mo: Mosby–Year Book; 1991:186. 30. Hale DE. Endocrine emergencies . In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine . 3rd ed. Baltimore, Md: Williams & Wilkins; 1993: 940-944. 31. Shefler AG, ed. The HSC Handbook of Pediatrics . 8th ed. St Louis, Mo: Mosby–Year Book; 1992:73-74. 32. Foster DW. Diabetes mellitus . In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . 12th ed. New York, NY: McGraw-Hill International Book Co; 1991:1751-1752. 33. Duck SC, Wyatt DT. Factors associated with brain herniation in the treatment of diabetic ketosis . J Pediatr . 1988;113:10-14.Crossref 34. Laron Z, Karp M. Diabetes mellitus in children and adolescents . In: Bertrand J, Rappoport R, Sizenko PC, eds. Pediatric Endocrinology: Physiology, Pathology and Clinical Aspects . 2nd ed. Baltimore, Md: Williams & Wilkins; 1993:604. 35. Harris GD, Fiordalisi I, Yu C. Intracranial pressure (ICP) during repair of diabetic ketoacidemia (DKA) in a rabbit model: the effect of fluid and electrolyte therapy . Pediatr Res . 1994;35:203A.

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Oct 1, 1994

References