Brun T H, Lagier P, Dejode J M, Attali T, Soula F, Granthil C
Département d'Anesthésie-Réanimation Nord, Hôpital Nord, Marseille.
Ann Fr Anesth Reanim. 1990;9(6):553-6. doi: 10.1016/s0750-7658(05)80228-x.
A case is reported of fatal acute cerebral oedema occurring in a 15-year-old child suffering diabetic ketoacidosis. He had severe gastro-enteritis, with a weight lose of 8 kg over a period of 8 days (initial weight = 50 kg). He was admitted in a stupor with pH 7.15, 129 mmol.l-1 natraemia, and 31 mmol.l-1 blood glucose concentration. Blood osmolaity was calculated to be 310 mosmol.l-1. He was rehydrated with 416 ml.h-1 normal saline and 416 ml.h-1 of 1.4% sodium bicarbonate. At the same time a total dose of 75 i.u. of ordinary insulin was given. After 2 h, the patient's condition suddenly worsened with unreactive coma, bilateral fixed mydriasis, respiratory pauses, and impairment of haemodynamic state (heart rate 150 b.min-1, blood pressure 80/50 mmHg). The diagnosis of cerebral oedema with severe intracranial hypertension was confirmed by different investigations. Despite ventilatory support and continued intensive care, the patient died a few hours later. It is concluded that some degree of subclinical brain swelling could be common occurrence during diabetic ketoacidosis, present maybe even before the start of treatment. Such cases of cerebral oedema are often reported, but the pathophysiological mechanisms remain unclear. However, unlike this case, rehydration must be moderate (less than 41.m-2.day-1), especially in case of hyponatraemia. Insulin and sodium bicarbonate must be used with care. Early rigorous clinical and biological monitoring is essential. Treatment should aim at a progressive correction of the metabolic disturbances.
报告了一例发生在一名15岁糖尿病酮症酸中毒患儿身上的致命性急性脑水肿病例。他患有严重的肠胃炎，在8天内体重减轻了8公斤（初始体重 = 50公斤）。他入院时处于昏迷状态，pH值为7.15，血钠浓度为129 mmol.l-1，血糖浓度为31 mmol.l-1。计算出血液渗透压为310 mosmol.l-1。给他以416 ml.h-1的生理盐水和416 ml.h-1的1.4%碳酸氢钠进行补液。同时给予了总量为75国际单位的普通胰岛素。2小时后，患者病情突然恶化，出现无反应性昏迷、双侧瞳孔固定散大、呼吸暂停以及血流动力学状态受损（心率150次/分钟，血压80/50 mmHg）。通过不同检查确诊为伴有严重颅内高压的脑水肿。尽管给予了通气支持和持续的重症监护，患者数小时后死亡。得出的结论是，在糖尿病酮症酸中毒期间，某种程度的亚临床脑肿胀可能是常见现象，甚至可能在治疗开始前就已存在。此类脑水肿病例经常被报道，但病理生理机制仍不清楚。然而，与本病例不同的是，补液必须适度（小于41 ml.m-2.day-1），尤其是在低钠血症的情况下。胰岛素和碳酸氢钠必须谨慎使用。早期严格的临床和生物学监测至关重要。治疗应旨在逐步纠正代谢紊乱。
