Risk Factors for Cerebral Edema in Children with Diabetic Ketoacidosis

Glaser, Nicole; Barnett, Peter; McCaslin, Ian; Nelson, David A.; Trainor, Jennifer L.; Louie, Jeffrey P.; Kaufman, Francine; Quayle, Kimberly S.; Roback, Mark G.; Malley, Richard; Kuppermann, Nathan

doi:10.1056/nejm200101253440404

Cited by 685 publications

(480 citation statements)

References 27 publications

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“…In a recent, multicenter study of children with diabetic ketoacidosis, for example, only 61 cases of cerebral edema were identified, despite a 15-year study period at ten major pediatric centers. 23 Similar limitations were experienced in a recent large study involving decision rules for computed tomography (CT) scanning of the brain in mild-to-moderate head injury. Despite the prospective enrollment of 1,044 children from four hospital EDs, and 83 (7.9%) ''positive'' CT scans, fewer than 1% of children with minor head injury required neurosurgical intervention.…”

Section: Introductionmentioning

confidence: 81%

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The Pediatric Emergency Care Applied Research Network (PECARN): Rationale, Development, and First Steps*

2003

Academic Emergency Medicine

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Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC), in the out-of-hospital as well as the emergency department (ED) and hospital settings, that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October 2001. PECARN is the first federally funded national network for research in EMSC. PECARN is the result of Cooperative Agreement grants funded through the Health Resources and Services Administration (HRSA) with the purpose of developing an infrastructure capable of overcoming inherent barriers to pediatric EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out-of-hospital care, patient transport, ED and in-hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the Network.

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Section: Introductionmentioning

confidence: 81%

“…Although the limited infrastructure of the PEM CRC is not funded, it has provided a platform for the conduct of several important collaborative research projects. 23,[44][45][46] With the exception of the PEM CRC, however, there are no collaborative research networks dedicated to PEM/EMSC.…”

Section: Conception and Development Of Pecarnmentioning

confidence: 99%

The Pediatric Emergency Care Applied Research Network (PECARN): Rationale, Development, and First Steps*

2003

Academic Emergency Medicine

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“…7 Second, a comparison of affected children who developed CE, with those treated for DKA who did not, found no significant association between rate of fluid administration and occurrence of CE, after controlling for initial illness severity. 4,7 Third, the widespread establishment of more conservative fluid replacement guidelines has not been associated with a concomitant fall in the rates of CE. 13 Fourth, imaging studies have found that pediatric patients with DKA show evidence of subclinical CE on MRI before therapy has begun.…”

Section: Discussionmentioning

confidence: 99%

“…The mortality rate for this devastating condition is 25%, and 5%-26% of its survivors suffer permanent neurological deficits. [4][5][6][7] Large case-control studies have identified several markers of increased illness severity as significant risk factors for the development of CE among pediatric DKA patients. 8 Risk factors include both patient-related and treatment-related variables.…”

Section: Introductionmentioning

confidence: 99%

Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments

Skitch

Valani

2015

CJEM

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Objective: Diabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences. Methods: Pediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema. Results: Responses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5-20 mL/kg) and length of time boluses should be administered (20-120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration. Conclusions: This is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

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“…It was recently reported, for example, that for children with DKA, those with low partial pressures of arterial carbon dioxide and high serum urea nitrogen levels at presentation and those treated with bicarbonate are at a higher risk of cerebral edema. 3 The use of any bicarbonate in this condition has been controversial for years, and this report suggests that it may be particularly dangerous for children.…”

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confidence: 99%

Hyperglycemic Emergencies: What Primary Care Providers Need to Know

Hirsch¹

2001

Clinical Diabetes

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Risk Factors for Cerebral Edema in Children with Diabetic Ketoacidosis

Abstract: Children with diabetic ketoacidosis who have low partial pressures of arterial carbon dioxide and high serum urea nitrogen concentrations at presentation and who are treated with bicarbonate are at increased risk for cerebral edema.

Cited by 685 publications

References 27 publications

The Pediatric Emergency Care Applied Research Network (PECARN): Rationale, Development, and First Steps*

The Pediatric Emergency Care Applied Research Network (PECARN): Rationale, Development, and First Steps*

Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments

Hyperglycemic Emergencies: What Primary Care Providers Need to Know

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