Investigators from multiple institutions conducted a retrospective study to identify risk factors for the occurrence of cerebral injury at presentation in children with diabetic ketoacidosis (DKA). The current study was a secondary analysis of data collected as part of the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) Trial. For the FLUID trial, children <18 years old, treated at 1 of 13 PECARN-affiliated emergency departments for DKA, diagnosed as a blood glucose >300 mg/dL, venous pH <7.25 or serum bicarbonate <15 mmol/L, and positive urine or blood test for ketones, were enrolled. For the current study, data on patients with cerebral injury that was apparent at presentation were abstracted. The designation of cerebral injury on presentation was based on an abnormal Glasgow Coma Score (GCS) at presentation and treatment with mannitol, hypertonic saline or intubation, or death, within 6 hours of initiation of treatment for DKA. Using ICD codes, children with DKA who met criteria for cerebral injury at presentation at study sites who were not enrolled in FLUID study were identified and included in the current analyses. The comparison group included patients in the FLUID trial who had no evidence of cerebral injury; patients treated for cerebral injury >6 hours after initiation of DKA therapy were excluded. Demographic, laboratory, treatment, and outcomes data were abstracted from the FLUD trial records or electronic medical records of study participants. Logistic regression was used to identify risk factors for cerebral injury at presentation, after adjusting for multiple confounders.
Data were analyzed on 48 children with cerebral injury at presentation for treatment of DKA and 1,227 with uncomplicated DKA. Among those with cerebral injury, the mean age was 9.7 ±4.7 years, mean glucose at presentation was 759 ±445 mg/dL, and median GCS was 9.5. Mannitol was used for treatment of cerebral injury in 34 children (71%), hypertonic saline in 23 (48%), and 12 received both treatments. Twenty patients required intubation. Median time from initiation of treatment for cerebral injury after initiation of DKA therapy was 20 minutes (interquartile range 8-51 minutes). Among children with DKA and cerebral injury at presentation, 40 (83.3%) recovered without apparent neurologic deficits, 6 (12.5%) had permanent neurologic disability, and 2 (4.2%) died. In the multivariate analysis, pH (adjusted odds ratio [aOR], 0.21; 95% CI, 0.15, 0.29; P <0.001) and blood urea nitrogen (BUN) (aOR, 1.09; 95% CI, 1.06, 1.12; P <0.001) were significant predictors of cerebral injury at presentation. Mean pH was 6.94 ±0.14 and 7.17 ±0.10, respectively, and mean BUN was 29.6 ±18.1 and 16.5 ±7.2 mmol/L, respectively, among patients with cerebral injury and those with uncomplicated DKA.
The authors conclude that lower pH and higher BUN levels were significantly associated with cerebral injury at presentation in children treated...