Subclinical Cerebral Edema in Children With Diabetic Ketoacidosis Randomized to 2 Different Rehydration Protocols

Abstract

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

Optic Nerve Sheath Diameter Measurement During Diabetic Ketoacidosis: A Pilot Study

“…Early identification of those at risk for DKA-CE continues to be a challenge despite multiple known risk factors1,24,25 Recent investigation suggests that impaired cerebral autoregulation may lead to vasogenic edema formation 4,5,26–28. This has also been supported by measurement of middle cerebral artery flow velocity via transcranial doppler ultrasonography 29,30.…”

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

“…14,15 Fifth, in a randomized trial of pediatric DKA patients, more aggressive fluid administration did not increase the occurrence of subclinical CE as measured by MRI. 16 The optimal fluid resuscitation strategy for the treatment of DKA is currently being studied through an ongoing randomized controlled trial. 17 The method of calculating maintenance fluid rates for pediatric DKA patients varies from one Canadian treatment protocol to another.…”

QUESTION 2: Do conservative rates of rehydration in children with diabetic ketoacidosis decrease the risk of cerebral oedema?

“…Only two8 10 well-designed studies clarify the fluid bolus regimen. However, in Glaser et al 8 the two treatment groups received significantly different fluid boluses. This occurred for two reasons: first, the regimens, themselves, were different between the groups, and second, additional fluid boluses could be prescribed at clinician discretion.…”

“…Glaser et al 4 produced a well-designed study (controlling for disease severity and first presentation of diabetes); however, even well-designed case–control studies are liable to have unrecognised biases. Since cerebral oedema is rare, Glaser et al 8 measured brain apparent diffusion coefficient on MRI as a marker of subclinical oedema in their randomised controlled trial. How accurately this represents the risk of clinical cerebral oedema is unclear.…”