RISK
FACTORS FOR CEREBRAL EDEMA IN CHILDREN WITH DIABETIC KETOACIDOSIS
Glaser,
N. et al. NEJM 2001; 344: 264-269.
BACKGROUND.
Cerebral edema is an uncommon but devastating complication of diabetic
ketoacidosis in children. Risk factors for this complication have not been
clearly defined.
METHODS.
In this multicenter study, we identified 61 children who had been hospitalized
for diabetic ketoacidosis within a 15-year period and in whom cerebral edema
had developed. Two additional groups of children with diabetic ketoacidosis but
without cerebral edema were also identified: 181 randomly selected children and
174 children matched to those in the cerebral-edema group with respect to age
at presentation, onset of diabetes (established vs. newly diagnosed disease),
initial serum glucose concentration, and initial venous pH. Using logistic
regression, we compared the three groups with respect to demographic
characteristics and biochemical variables at presentation and compared the
matched groups with respect to therapeutic interventions and changes in
biochemical values during treatment.
RESULTS.
A comparison of the children in the cerebral-edema group with those in the
random control group showed that cerebral edema was significantly associated
with lower initial partial pressures of arterial carbon dioxide (relative risk
of cerebral edema for each decrease of 7.8 mm Hg [representing 1 SD], 3.4; 95 percent
confidence interval, 1.9 to 6.3; P<0.001) and higher initial serum urea
nitrogen concentrations (relative risk of cerebral edema for each increase of 9
mg per deciliter [3.2 mmol per liter] [representing 1 SD], 1.7; 95 percent
confidence interval, 1.2 to 2.5; P=0.003). A comparison of the children with
cerebral edema with those in the matched control group also showed that
cerebral edema was associated with lower partial pressures of arterial carbon
dioxide and higher serum urea nitrogen concentrations. Of the therapeutic
variables, only treatment with bicarbonate was associated with cerebral edema,
after adjustment for other covariates (relative risk, 4.2; 95 percent
confidence interval, 1.5 to 12.1; P=0.008).
CONCLUSIONS.
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.