ADC changes during DKA treatment (reflective of vasogenic CE) do not appear to be substantially affected by the rate of intravenous fluid administration.

Objective To use near infrared spectroscopy (NIRS), which indirectly detects cerebral hyperemia by measuring abnormal elevations in cerebral regional oxygen saturation (rSO2), in children during diabetic ketoacidosis (DKA) treatment. Study design We randomized children 8–18 years with DKA to either more rapid or slower IV fluid treatment (n=19 total DKA episodes). NIRS was used to measure rSO2 during DKA treatment. NIRS monitoring began as soon as informed consent was obtained and continued until the patient was transferred out of the critical care unit. Results rSO2 values above the normal range (>80%) were detected in 17 of 19 DKA episodes (mean rSO2 during initial 8 hours of DKA treatment: 86% ± 7%, range 65–95%). Elevated rSO2 values were detected as early as the second hour of DKA treatment and persisted for as long as 27 hours. Hourly mean rSO2 levels during treatment did not differ significantly by fluid treatment group. Conclusions During DKA treatment, children have elevated rSO2 values consistent with cerebral hyperemia. Hyperemia occurs as early as the second hour of DKA treatment and may persist for 27 hours or more. Cerebral rSO2 levels during treatment did not differ significantly in patients treated with slower versus more rapid intravenous rehydration.

SUMMARY:Recent data suggest that DKA may contribute to cognitive impairment in children with type 1 DM. We measured the NAA/Cr ratio in a teenager during and following 2 separate episodes of DKA without clinically apparent cerebral edema. The NAA/Cr ratio decreased during DKA and improved following recovery. However, the NAA/Cr value was lower after the second episode of DKA (1.76) than after the first (1.97). These findings provide support for the hypothesis that neuronal injury may result from DKA.ABBREVIATIONS: BUN ϭ blood urea nitrogen; Cr ϭ creatine; DKA ϭ diabetic ketoacidosis; DM ϭ diabetes mellitus; NAA ϭ N-acetylaspartate S everal studies suggest that type 1 DM can lead to long-term alterations in cognitive function, and some studies have documented structural abnormalities of the brain in individuals with type 1 DM.1,2 The cause of brain injury in type 1 DM is not well understood, but recent data suggest that DKA may be strongly associated with cognitive impairment in children.3 Children who experienced an episode of DKA showed significantly decreased memory capacity compared with children with type 1 DM without a history of DKA.3 These data suggest that DKA may be an important factor causing permanent cerebral injury. Case ReportA 14-year-old boy with type 1 DM experienced 2 episodes of DKA, separated by 2 months, without clinically apparent cerebral edema. At the first presentation of DKA, his initial blood glucose level was 780 mg/dL; pH, 6.99; serum bicarbonate level, 8 mmol/L; and BUN level, 20 mg/dL. At the time of the second presentation, his initial blood glucose level was 986 mg/dL; pH, 6.98; serum bicarbonate level, 8 mmol/L; and BUN, 27 mg/dL. He had normal mental status at presentation and maintained normal mental status (hourly Glasgow Coma Scale scores of 15) during both episodes, suggesting that he did not develop clinically relevant cerebral edema.This case review was approved by our institutional review board. MR spectroscopy was performed on a 3T imaging system (8-channel Excite HD, OS Version 12M5; GE Healthcare, Milwaukee, Wisconsin) at 2 time points: 9 -12 hours after initial presentation of DKA and after recovery from the episode (Ͼ72 hours after treatment, after resolution of metabolic acidosis and ketosis). A single voxel (8 cm 3 ) at the right basal ganglia was studied using a Probe-P sequence with a TR/TE of 1500/144 ms. The NAA peak was identified according to its chemical shift at 2.02 ppm, and Cr, at 3.02 ppm. The heights of the peaks, which reflect the relative corresponding metabolite concentrations, were used to calculate the ratio of NAA/Cr. The basal ganglia were chosen as the point of interrogation because this region is especially susceptible to injury caused by DKA-related cerebral edema. The NAA/Cr ratio was lower during acute DKA than after recovery in both episodes (1.87 versus 1.97 for the first episode, 1.56 versus 1.76 for the second episode, Fig 1). More important, the NAA/Cr ratio was lower after recovery from the second episode of DKA (1.76) than after reco...

Introduction:To determine if increased trauma team response results in alterations in resource use in a population of children <6 years, especially in those least injured.Methods:We conducted a retrospective before and after study of children <6 years sustaining blunt trauma and meeting defined prehospital criteria. We compared hospitalization rates and missed injuries (injuries identified after discharge from the emergency department/hospital) among patients with and without an upgraded trauma team response. We compared the computed tomography (CT) rate and laboratory testing rate among minimally injured patients (Injury Severity Score [ISS] 6).Results:We enrolled 352 patients with 180 (mean age 2.7 ± 1.5 years) in the upgrade cohort and 172 (mean age 2.6 ± 1.5 years) in the no-upgrade cohort. Independent predictors of hospital admission in a regression analysis included: Glasgow Coma Scale <14 (odds ratio [OR]=11.4, 95% confidence interval [CI] 2.3, 56), ISS (OR=1.55, 95% CI 1.33, 1.81), and evaluation by the upgrade trauma team (OR=5.66, 95% CI 3.14, 10.2). In the 275 patients with ISS <6, CT (relative risk=1.34, 95% CI 1.09, 1.64) and laboratory tests (relative risk=1.71, 95% CI 1.39, 2.11) were more likely to be obtained in the upgrade cohort as compared to the no-upgrade cohort. We identified no cases of a missed diagnosis.Conclusion:Increasing the trauma team response based upon young age results in increased resource use without altering the rate of missed injuries. In hospitals with emergency department physicians capable of evaluating and treating injured children, increasing ED trauma team resources solely for young age of the patient is not recommended.

In a randomized controlled trial of two modalities for local anesthesia in infant LPs, J-Tip was not superior to TA cream as measured by pain control or physiologic changes. Infant LPs performed with J-Tip were twice as likely to be successful.