Abstract
Objectives
Cerebral edema (CE) remains one of the most feared complications of diabetic ketoacidosis (DKA) with severe morbidity and mortality. The use of computerized tomography (CT) scan in the setting of suspected cerebral edema in DKA has been minimally studied. The objective of our study was to evaluate the utility of CT scans in children with suspected cerebral edema, and secondarily to analyze the various patient characteristics of those with and without cerebral edema.
Methods
We performed a retrospective chart review of all the children with DKA secondary to T1DM admitted to our tertiary PICU in order to obtain demographic data, laboratory results, and their treatment course. Differences between the groups of suspected CE and no suspected CE were compared using linear and logistic regression for continuous and binary variables respectively.
Results
We identified 251 patients with DKA, 12 of which had suspected CE; 67% (8/12) of those patients received head CT and 87.5% (7/8) of them were read as normal. On the other hand, 33% (4/12) did not receive CT scan of head, and yet three of the four patients were treated for CE.
Conclusions
In our cohort of patients, CT results did not influence CE treatment or lack thereof; most patients with suspected CE were treated with or without head CT findings of CE, indicating that imaging has very little utility in our cohort of patients. In some cases, the use of head CT delayed the onset of treatment for CE.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. Dr. Wilkinson collected data, carried out data analysis, drafted the initial manuscript, and reviewed and revised the manuscript. Ms Nair collected data, carried out data analysis, and helped draft the initial manuscript, Dr. Sanghamitra helped design the study and collect preliminary data. Drs. Ambati and Sanchez conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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Competing interests: Authors state no conflict of interest.
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Informed consent: Informed consent was waived for this study by our institution IRB.
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Ethical approval: The local Institutional Review Board deemed the study exempt from review. Albany Medical Center Institutional Review Board IRB #5044.
References
1. Long, B, Koyfman, A. Emergency medicine myths: cerebral edema in pediatric diabetic ketoacidosis and intravenous fluids. J Emerg Med 2017;53:212–21. https://doi.org/10.1016/j.jemermed.2017.03.014.Search in Google Scholar PubMed
2. Glaser, NS, Wootton-Gorges, SL, Buonocore, MH, Marcin, JP, Rewers, A, Strain, J, et al.. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes 2006;7:75–80. https://doi.org/10.1111/j.1399-543X.2006.00156.x.Search in Google Scholar PubMed
3. Azova, S, Rapaport, R, Wolfsdorf, J. Brain injury in children with diabetic ketoacidosis: review of the literature and a proposed pathophysiologic pathway for the development of cerebral edema. Pediatr Diabetes 2021;22:148–60. https://doi.org/10.1111/pedi.13152.Search in Google Scholar PubMed
4. Levin, DL. Cerebral edema in diabetic ketoacidosis. Pediatr Crit Care Med 2008;9:320–9. https://doi.org/10.1097/PCC.0b013e31816c7082.Search in Google Scholar PubMed
5. Wolfsdorf, J, Glaser, N, Sperling, MA, American Diabetes, A. Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care 2006;29:1150–9. https://doi.org/10.2337/dc06-9909.Search in Google Scholar
6. Lawrence, SE, Cummings, EA, Gaboury, I, Daneman, D. Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr 2005;146:688–92. https://doi.org/10.1016/j.jpeds.2004.12.041.Search in Google Scholar PubMed
7. Mayer-Davis, EJ, Kahkoska, AR, Jefferies, C, Dabelea, D, Balde, N, Gong, CX, et al.. ISPAD clinical practice consensus guidelines 2018: definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes 2018;19(27 Suppl):7–19. https://doi.org/10.1111/pedi.12773.Search in Google Scholar PubMed PubMed Central
8. Levitsky, LL. Symptomatic cerebral edema in diabetic ketoacidosis: the mechanism is clarified but still far from clear. J Pediatr 2004;145:149–50. https://doi.org/10.1016/j.jpeds.2004.05.030.Search in Google Scholar PubMed
9. Brenner, D, Elliston, C, Hall, E, Berdon, W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289–96. https://doi.org/10.2214/ajr.176.2.1760289.Search in Google Scholar PubMed
10. Brenner, DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 2002;32:228–31. https://doi.org/10.1007/s00247-002-0671-1.Search in Google Scholar PubMed
11. Brenner, DJ, Hall, EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84. https://doi.org/10.1056/NEJMra072149.Search in Google Scholar PubMed
12. Soto-Rivera, CL, Asaro, LA, Agus, MS, DeCourcey, DD. Suspected cerebral edema in diabetic ketoacidosis: is there still a role for head CT in treatment decisions? Pediatr Crit Care Med 2017;18:207–12. https://doi.org/10.1097/PCC.0000000000001027.Search in Google Scholar PubMed PubMed Central
13. Muir, AB, Quisling, RG, Yang, MC, Rosenbloom, AL. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care 2004;27:1541–6. https://doi.org/10.2337/diacare.27.7.1541.Search in Google Scholar PubMed
14. Glaser, N, Barnett, P, McCaslin, I, Nelson, D, Trainor, J, Louie, J, et al.. Risk factors for cerebral edema in children with diabetic ketoacidosis. The pediatric emergency medicine collaborative research committee of the American academy of pediatrics. N Engl J Med 2001;344:264–9. https://doi.org/10.1056/nejm200101253440404.Search in Google Scholar
15. Gonzalez Pannia, P, Balboa, R, Navarro, R, Nocita, MF, Ferraro, M, Mannucci, C. Prevalence of cerebral edema among diabetic ketoacidosis patients (Prevalencia de edema cerebral en pacientes con cetoacidosis diabetica). Arch Argent Pediatr 2020;118:332–6. https://doi.org/10.5546/aap.2020.eng.332.Search in Google Scholar PubMed
16. Patel, A, Singh, D, Bhatt, P, Thakkar, B, Akingbola, OA, Srivastav, SK. Incidence, trends, and outcomes of cerebral edema among children with diabetic ketoacidosis in the United States. Clin Pediatr (Philadelphia) 2016;55:943–51. https://doi.org/10.1177/0009922815617975.Search in Google Scholar PubMed
17. Yaneva, NY, Konstantinova, MM, Iliev, DI. Risk factors for cerebral oedema in children and adolescents with diabetic ketoacidosis. Biotechnol Biotechnol Equip 2016;30:1142–7. https://doi.org/10.1080/13102818.2016.1221740.Search in Google Scholar
18. Edge, JA, Hawkins, MM, Winter, DL, Dunger, DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child 2001;85:16–22. https://doi.org/10.1136/adc.85.1.16.Search in Google Scholar PubMed PubMed Central
19. Decourcey, DD, Steil, GM, Wypij, D, Agus, MS. Increasing use of hypertonic saline over mannitol in the treatment of symptomatic cerebral edema in pediatric diabetic ketoacidosis: an 11-year retrospective analysis of mortality. Pediatr Crit Care Med 2013;14:694–700. https://doi.org/10.1097/PCC.0b013e3182975cab.Search in Google Scholar PubMed
20. Glaser, N. Cerebral injury and cerebral edema in children with diabetic ketoacidosis: could cerebral ischemia and reperfusion injury be involved? Pediatr Diabetes 2009;10:534–41. https://doi.org/10.1111/j.1399-5448.2009.00511.x.Search in Google Scholar PubMed
21. Edge, JA, Roy, Y, Bergomi, A, Murphy, NP, Ford-Adams, ME, Ong, KK, et al.. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediatr Diabetes 2006;7:11–5. https://doi.org/10.1111/j.1399-543X.2006.00143.x.Search in Google Scholar PubMed
22. Rosenbloom, AL. Intracerebral crises during treatment of diabetic ketoacidosis. Diabetes Care 1990;13:22–33. https://doi.org/10.2337/diacare.13.1.22.Search in Google Scholar PubMed
23. Ho, J, Mah, JK, Hill, MD, Pacaud, D. Pediatric stroke associated with new onset type 1 diabetes mellitus: case reports and review of the literature. Pediatr Diabetes 2006;7:116–21. https://doi.org/10.1111/j.1399-543X.2006.00151.x.Search in Google Scholar PubMed
24. Vavilala, MS. Imaging for cerebral edema in diabetic ketoacidosis: time to zap the CT? Pediatr Crit Care Med 2017;18:281–2. https://doi.org/10.1097/PCC.0000000000001037.Search in Google Scholar PubMed PubMed Central
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