Soto-Rivera Carmen L, Asaro Lisa A, Agus Michael S D, DeCourcey Danielle D
1Division of Medicine Critical Care, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA. 2Division of Endocrinology, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA. 3Department of Cardiology, Boston Children's Hospital, Boston, MA.
Pediatr Crit Care Med. 2017 Mar;18(3):207-212. doi: 10.1097/PCC.0000000000001027.
Neurologic deterioration associated with cerebral edema in diabetic ketoacidosis is typically sudden in onset, progresses rapidly, and requires emergent treatment. The utility of brain imaging by head CT in decisions to treat for cerebral edema has not been previously studied. The objective of this study was to describe the characteristics of pediatric patients with diabetic ketoacidosis who develop altered mental status and evaluate the role of head CT in this cohort.
Retrospective analysis of clinical, biochemical, and radiologic data.
Tertiary care children's hospital (2004-2010).
Six hundred eighty-six admissions of patients (< 26 yr) with diabetic ketoacidosis.
None.
Altered mental status was documented during 96 of 686 diabetic ketoacidosis admissions (14%). Compared with alert patients, those with altered mental status were younger (median, 12.0 vs 13.1 yr; p = 0.007) and more acidotic (pH, 7.04 vs 7.19; p < 0.001), with higher serum osmolality (328 vs 315 mOsm/kg; p < 0.001) and longer hospital length of stay (4.5 vs 3 d; p = 0.002). Head CT was performed during 60 of 96 diabetic ketoacidosis admissions with altered mental status (63%), 16 (27%) of which had abnormal results. Hyperosmolar therapy for cerebral edema was given during 23 of the 60 admissions (38%), during which 12 (52%) had normal head CT results, eight of these 12 (67%) after cerebral edema treatment and four (33%) before. Of the 11 admissions with abnormal head CT results that received hyperosmolar therapy, four head CT scan (36%) occurred after hyperosmolar treatment and seven (64%) before. For the 11 admissions with head CT before cerebral edema treatment, there was a median 2-hour delay between head CT and hyperosmolar therapy.
In this single-center retrospective study, there was no evidence that decisions about treatment of patients with diabetic ketoacidosis and suspected cerebral edema were enhanced by head CT, and head CT may have led to a significant delay in hyperosmolar therapy.
糖尿病酮症酸中毒相关的脑水肿所致神经功能恶化通常起病突然，进展迅速，需要紧急治疗。此前尚未研究头部CT脑成像在糖尿病酮症酸中毒脑水肿治疗决策中的作用。本研究的目的是描述发生精神状态改变的糖尿病酮症酸中毒患儿的特征，并评估头部CT在该队列中的作用。
对临床、生化和放射学数据进行回顾性分析。
三级医疗儿童医院（2004 - 2010年）。
686例年龄小于26岁的糖尿病酮症酸中毒患者的入院病例。
无。
686例糖尿病酮症酸中毒入院病例中有96例（14%）记录有精神状态改变。与意识清醒的患者相比，精神状态改变的患者更年轻（中位数分别为12.0岁和13.1岁；p = 0.007），酸中毒更严重（pH值分别为7.04和7.19；p < 0.001），血清渗透压更高（328 vs 315 mOsm/kg；p < 0.001），住院时间更长（4.5天 vs 3天；p = 0.002）。96例精神状态改变的糖尿病酮症酸中毒入院病例中有60例（63%）进行了头部CT检查，其中16例（27%）结果异常。60例入院病例中有23例（38%）接受了针对脑水肿的高渗治疗，其中12例（52%）头部CT结果正常，这12例中有8例（67%）是在脑水肿治疗后，4例（33%）是在治疗前。接受高渗治疗的11例头部CT结果异常的入院病例中，4例头部CT扫描（36%）是在高渗治疗后进行的，7例（64%）是在治疗前。对于11例在脑水肿治疗前进行头部CT检查的入院病例，头部CT检查与高渗治疗之间的中位延迟时间为2小时。
在这项单中心回顾性研究中，没有证据表明头部CT能改善糖尿病酮症酸中毒合并疑似脑水肿患者的治疗决策，而且头部CT可能导致高渗治疗出现显著延迟。
