Correspondence

Risk Factors for Cerebral Edema in Children with Diabetic Ketoacidosis

N Engl J Med 2001; 344:1556May 17, 2001

Article

To the Editor:

The study by Glaser et al. (Jan. 25 issue)1 identified risk factors for the development of symptomatic cerebral edema in children with diabetic ketoacidosis. Of the 61 children in whom symptomatic cerebral edema developed, 57 percent recovered completely, 21 percent had permanent neurologic damage, and 21 percent died. The investigators did not identify the risk factors for death from cerebral herniation or for permanent neurologic damage. It would be clinically relevant to compare the children who died or had permanent neurologic damage with those who did not have symptomatic cerebral edema or who had symptomatic cerebral edema but recovered completely.

The authors conclude that the rate of fluid administration and the tonicity of the fluid that was administered, when analyzed separately, were not related to the risk of cerebral edema. However, they did not evaluate whether the use of hypotonic fluid, when administered at a high rate, was a risk factor for cerebral edema. It is possible that both of these factors are necessary to increase the risk of cerebral edema. Finally, the authors identified three children who had cerebral edema before the initiation of therapy. Did these children receive excessive oral rehydration with hypotonic fluid (such as water) at home, before their presentation at the hospital?

Bassam M. Gebara, M.D.
William Beaumont Hospital, Royal Oak, MI 48073

1 References

1. 1

   Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med 2001;344:264-269
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Gebara raises several issues that merit responses. First, limiting the cerebral-edema group to patients with adverse outcomes would be relevant only if interventions for the treatment of cerebral edema were ineffective. Although there is limited information about therapy for cerebral edema in children with diabetic ketoacidosis, case reports suggest that prompt initiation of hyperosmolar therapy may be beneficial.1,2 We therefore cannot assume that the children who survived without sequelae had a less severe form of the disease than those who had adverse outcomes.

Second, although there are theoretical reasons why rapid administration of hypotonic fluids might contribute to cerebral edema, neither the rate of fluid administration nor the rate of sodium administration was significantly associated with cerebral edema in the patients we studied. In addition, in a subanalysis that we conducted, an interaction term combining the rates of fluid and sodium administration was not significantly associated with cerebral edema. We recommend that physicians caring for children with diabetic ketoacidosis administer rehydration therapy to these patients at moderate rates and that isotonic fluids be used for the initial several hours.

Finally, we do not know whether children who had cerebral edema before in-hospital therapy for diabetic ketoacidosis ingested excess hypotonic fluid at home. Most children with severe diabetic ketoacidosis, however, have a history of persistent vomiting and present with gastrointestinal ileus. It is therefore unlikely that they could both ingest and absorb substantial quantities of fluid at the same time.

Nicole Glaser, M.D.
Nathan Kuppermann, M.D., M.P.H.
University of California, Davis, School of Medicine, Davis, CA 95616

2 References

1. 1

   Franklin B, Liu J, Ginsberg-Fellner F. Cerebral edema and ophthalmoplegia reversed by mannitol in a new case of insulin-dependent diabetes mellitus. Pediatrics 1982;69:87-90
   Web of Science | Medline

2. 2

   Shabbir N, Oberfield SE, Corrales R, Kairam R, Levine LS. Recovery from symptomatic brain swelling in diabetic ketoacidosis. Clin Pediatr (Bologna) 1992;31:570-573
   CrossRef

Citing Articles (1)

Citing Articles

1. 1

   Daniel L. Levin. (2008) Cerebral edema in diabetic ketoacidosis. Pediatric Critical Care Medicine 9:3, 320-329
   CrossRef