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Risk factors for developing brain herniation during diabetic ketoacidosis
C P Mahoney1, B W Vlcek, M DelAguila
1Department of Pediatric Endocrinology, Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA.
Insights
Diabetic ketoacidosis (DKA) in children can lead to brain herniation. Severe acidosis and rapid fluid rates increase risk, while controlled hydration prevents it.
Area of Science:
- Pediatrics
- Endocrinology
- Neurology
Background:
- Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus.
- Brain herniation is a rare but severe complication of DKA treatment.
- Identifying risk factors for brain herniation is crucial for patient management.
Purpose of the Study:
- To investigate the incidence and risk factors of brain herniation in children with DKA.
- To evaluate the association between initial fluid resuscitation rates and brain herniation.
- To determine optimal fluid management strategies to prevent DKA-related brain herniation.
Main Methods:
- Retrospective chart review of children admitted with DKA over 12 years.
- Analysis of clinical data including blood pH, PCO2, and initial fluid administration rates.
- Comparison of brain herniation incidence based on acidosis severity and fluid therapy rates.
Main Results:
- Nine out of 153 children experienced brain herniation.
- Severe acidosis (pH < 7.1) and hypercapnia (PCO2 < 20 mm Hg) were significant risk factors.
- Fluid administration exceeding 50 mL/kg in the first 4 hours was associated with increased brain herniation risk.
Conclusions:
- Maintaining adequate pH and PCO2 levels is vital in DKA management.
- Aggressive initial fluid resuscitation ( > 50 mL/kg/4h) in severe DKA increases brain herniation risk.
- Controlled fluid administration is recommended to mitigate DKA-related brain herniation.
Abstract:
The charts were reviewed of children admitted in diabetic ketoacidosis (DKA) to one hospital within 12 years. The frequency of brain herniation after admission was nine of 153 children admitted for one or more episodes of DKA. The severity of acidosis and hypercapnea were the most reliable risk factors. None of the children who maintained a blood pH greater than 7.1 and a capillary blood partial pressure of carbon dioxide (PCO2) greater than 20 mm Hg manifested brain herniation. The rate of initial fluid administration in severe DKA was also a risk factor. Of 119 patients having a blood pH less than 7.1 or PCO2 less than 20 mm Hg, none of 32 receiving less than 25 mL/kg, one of 42 receiving 25-50 mL/kg, and eight of 40 receiving more than 50 mL/kg of intravenous fluid during the first (in Patient 9, the second) 4 hours of therapy sustained brain herniation. Equally dehydrated unaffected patients initially receiving 25-50 mL/kg/4 hours of intravenous fluid did not develop signs of hypovolemia or worsening DKA. In this series, hydrating at a rate greater than 50 mL/kg during the first 4 hours offered no advantage and was associated with an increased risk of brain herniation.