Lack of evidence of cerebral oedema in adults treated for diabetic ketoacidosis with fluids of different tonicity

Azzopardi, Joseph; Gatt, Alex; Zammit, Anthony; Alberti, George

doi:10.1016/s0168-8227(02)00019-0

Cited by 24 publications

(8 citation statements)

References 7 publications

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“…There have been limited numbers of prospective trials, although given the rarity of this outcome, these have been inadequately powered (16, 20–23, 28, 35). Others have argued that rapid hydration is not a concern as cerebral oedema, as demonstrated by CT imaging of the brain, may be present prior to hydration and relates to the severity of initial acidosis rather than medical intervention (31, 34). …”

Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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BackgroundDiabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs).ObjectiveTo review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes.MethodsOvid Medline searches were conducted with limits “all adult” and published between “1973 to current” applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers’ assessment of title, abstract, and availability.ResultsA total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over “sliding scale” insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1–2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes.ConclusionThere are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.

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Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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“…[19] Although cerebral edema is rarely seen in these cases except in children or in patients with pure HHS, [20] a neurological examination and radiological study should be considered, as the condition can be fatal. Severe dehydration and hyperviscosity of the blood increase the risk of thromboembolism in patients with HHS.…”

Section: Discussionmentioning

confidence: 99%

A case report of hyperosmolar hyperglycemic state in a 7-year-old child

2017

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Rationale:A hyperosmolar hyperglycemic state (HHS) is a rare presentation of a hyperglycemic crisis in children with diabetes mellitus. As this condition can be fatal and has high morbidity, early recognition and proper management are necessary for a better outcome. Here, we report a rare case of HHS as the first presentation of type 1 diabetes mellitus (T1DM) in a 7-year-old girl.Patient concerns:The patient was admitted due to polyuria and weight loss in the past few days. The initial blood glucose level was 1167mg/dL.Diagnoses:On the basis of clinical manifestations and laboratory results, she was diagnosed with T1DM and HHS.Interventions:Treatment was started with intravenous fluid and regular insulin.Outcomes:She was discharged without any complications related to HHS and is being followed up in the outpatient clinic with split insulin therapy.Lessons:As the incidence of T1DM is increasing, emergency physicians and pediatricians should be aware of HHS to make an early diagnosis for appropriate management, as it can be complicated in young children with T1DM.

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“…Subsequently, another ∼160 cases have been added. These reports have provided incidence data and have emphasized the idiosyncratic nature of the occurrence of CE and the absence of iatrogenic causation 66,67…”

Section: Complications Of Dka or Its Treatmentmentioning

confidence: 99%

The management of diabetic ketoacidosis in children

Rosenbloom

2010

Diab Ther

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The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%–70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1–2 hours; an initial bolus of 10–20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%–10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.

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Lack of evidence of cerebral oedema in adults treated for diabetic ketoacidosis with fluids of different tonicity

Cited by 24 publications

References 7 publications

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

A case report of hyperosmolar hyperglycemic state in a 7-year-old child

The management of diabetic ketoacidosis in children

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