Palabras clave
fluidoterapia
edema encefálico. diabetic ketoacidosis
fluid therapy
cerebral edema
Cómo citar
Resumen
Introducción:
La cetoacidosis diabética (CAD) resulta de una deficiencia de insulina asociada a un aumento de hormonas contrarreguladoras. Acarrea una mortalidad entre el 0,15 y el 0,30%, siendo el edema cerebral su principal causa. La terapéutica de la CAD se basa en la hidratación, insulinoterapia, administración de electrolitos, además del tratamiento del factor precipitante.
Objetivo:
Determinar la incidencia de CAD en UTIPs durante el período 01/01/2013 a 31/12/2017.
Describir y analizar los datos epidemiológicos, el tratamiento instaurado y determinar la existencia de factores predictores de edema cerebral.
Pacientes y Métodos:
Todos los pacientes con diagnóstico de CAD ingresados en 8 UTIP de 7 hospitales de Argentina.
Resultados:
La incidencia de CAD en las UTIP fue del 6‰. Se analizaron 56 casos, edad de 11 años (8-14). El 53,6% fueron Diabetes Mellitus debut, presentando al ingreso pH 7,07 (6,96-7,13) y HCO3 de 5 mEq/L (3,65-6,7) respectivamente. El volumen de líquidos EV aportados mediante PHP en las primeras 24 horas fue de 4050 (3200-4520) ml/m2. El 43% de los pacientes presentó edema cerebral clínico. El PIM II, el PH y estado neurológico al ingreso, la administración de HCO3, el volumen de líquidos aportado y la dosis acumulada de insulina se asociaron con edema cerebral (p<0,05). La estancia en la UTIP fue de 3 días (2-5) y la mortalidad del 3,6% (2/56).
Conclusión:
La incidencia de CAD fue del 6‰. La severidad de la CAD, el aporte de HCO3, la hiperhidratación y la mayor dosis acumulada de insulina se asociaron a edema cerebral.
Summary:
Introduction:
Diabetic ketoacidosis (DKA) results from an insulin deficiency combined with an increase in counterregulatory hormones. It carries a mortality between 0.15 and 0.30%, being the cerebral edema the main cause of death. DKA treatment is based on hydration, insulin therapy, administration of electrolytes, in addition to the treatment of the triggering factor.
Objective:
To determine the incidence of DKA in pediatric intensive care units (PICU) during the period 01/01/2013 to 12/31/2017.
To describe and analyze the epidemiological data, established treatment and to determine the existence of predictors of cerebral edema.
Patients and Methods:
All patients with diagnosis of DKA admitted to 8 PICU of 7 hospitals in Argentina.
Results:
DKA incidence in PICU was 6 ‰. We analyzed 56 cases, median age of 11 years old (8-14). The 53.6% were Diabetes Mellitus (DM) debut, presenting at the admission time, pH 7.07 (6,96-7,13) and HCO3 of 5 mEq/L (3,65-6,7), respectively. The IV fluid volume provided by PHP in the first 24 hours was 4050 (3200-4520) ml/m2. The 43% of patients presented clinical cerebral edema. PIM II, PH and neurological status at admission time, HCO3 administration, fluid volume provided and insulin cumulative dose were associated with cerebral edema (p <0.05). The length of PICU stay was 3 days (2-5) and the mortality was 3.6% (2/56).
Conclusion:
DKA incidence in PICU was 6 ‰. DKA severity, HCO3 supply, hyperhydration and high insulin accumulated dose were associated with cerebral edema.
Citas
Chiasson J, Aris-Jilwan N, Bélanger R, et al. Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state. CMAJ. 2003; 168:859- 866.
Umpierrez G, Murphy M, Kitabchi A. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Diabetes Spectrum 2002; 15:28-36.
Wolfsdorf J, Craig M, Daneman D, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes. 2009; 10(Suppl 12):118-133.
Rewers A, Klingensmith G, Davis C, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics.2008; 121(5):e1258-66.
Usher-Smith JA, Thompson M, Ercole A, et al. Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review. DiabetologÃa 2012: 55: 2878–2894
Wolfsdorf E, Allgrove J, Craig M, et al, Diabetic ketoacidosis and hyperglycemic hyperosmolar state. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium. Pediatric Diabetes 2014; 15(Suppl. 20): 154–179.
Levin D. Cerebral edema in diabetic ketoacidosis. Pediatr Crit Care Med 2008 ; 9 : 320 – 9
Edge JA, Hawkins MM, Winter DL, Dunger DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child 2001; 85:16–22
Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis: the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med 2001; 344:264–269
Marcin JP, Glaser N, Barnett P, et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002;141:793–797
Muir A, Quisling G, Yang M, et al: Cerebral edema in childhood diabetic ketoacidosis. Diabetes Care 2004; 27:1541–1546
Fiordalisi I, Novotny WE, Holbert D, Finberg L, Harris GD. An 18-yr prospective study of pediatric diabetic ketoacidosis: an approach to minimizing the risk of brain herniation during treatment. Pediatr Diabetes 2007: 8: 142–149
Ramos O, Ferraro M, Barbeito S. Cetoacidosis diabética. En Voyer L, ed. Criterios de diagnóstico y tratamiento en PediatrÃa. 2.a ed. Buenos Aires: Journal; 2006.Págs.95-100
Ozuna Blanca. Cetoacidosis diabética: controversias en el manejo inicial complicaciones en emergencias y cuidados crÃticos. 8° congreso argentino de emergencias y cuidados crÃticos en pediatrÃa. 2017. CABA. Presentacion oral. [Acceso: 5 de Abril de 2018]. Disponible en: http://www.sap.org.ar/docs/Congresos2017/Emergencias/PDF/Ozuna_complicaciones
Kitabchi A, Umpierrez G, Miles J, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32:1335–43.
Savage M, Dhatariya K, Kilvert A, et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med 2011; 28:508–15.
Edge J, Jakes R, Hawkins M, et al. The UK case–control study of cerebral oedema complicating diabetic ketoacidosis in children. Diabetologia 2006; 49: 2002–2009
Hsia D, Tarai S, Alimi A, et al. Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema. Pediatr Diabetes. 2015; 16:338–344.
Kuppermann N, Ghetti S, Schunk J, et al; for the PECARN DKA FLUID Study Group. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018; 378:2275-87.
Nallasamy K, Jayashree M, Singhi S, et al. Low-Dose vs Standard-Dose Insulin in Pediatric Diabetic Ketoacidosis A Randomized Clinical Trial. JAMA Pediatr. 2014;168(11):999-1005
Edge JA, Roy Y, Bergomi A, et al: Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediatr Diabetes 2006; 7:11–15.
Vavilala M. Treating Cerebral Edema in Diabetic Ketoacidosis: Caveats in Extrapolating from Traumatic Brain Injury. Pediatr Crit Care Med. 2013 September; 14(7).
Soto-Rivera C, Asaro L, Agus M, et al: Suspected Cerebral Edema in Diabetic Ketoacidosis: Is There Still a Role for Head CT in Treatment Decisions? Ped Crit Care Med 2017; 18:207–212
O’Brien NF, Mella C: Brain tissue oxygen¬ation–guided management of diabetic keto¬acidosis induced cerebral edema. Pediatr Crit Care Med 2012; 13:e383–e388
Ma L, Roberts JS, Pihoker C, et al. Transcranial Doppler Based Assessment of Cerebral Autoregulation in Critically Ill Children during Diabetic Ketoacidosis Treatment. Pediatr Crit Care Med 2014; 15:742–749.
Hansen, G., et al., Serial optic nerve sheath diameter ultrasonography during pediatric diabetic ketoacidosis management: A pilot study. Journal of Diabetes and Its Complications 2016; 30 (8): 1600-1602
Decourcey D, Steil G, Wypij D, et al: Increasing Use of Hypertonic Saline Over Mannitol in the Treatment of Symptomatic Cerebral Edema in Pediatric Diabetic Ketoacidosis: An 11-Year Retrospective Analysis of Mortality. Pediatr Crit Care Med 2013; 14:694–700
Ferreira J, Penazzi M, Taboada M, y col. Comparación de dos sistemas de aporte de soluciones hidroelectrolÃticas para el manejo de la cetoacidosis diabética: ensayo clÃnico controlado y aleatorizado en niños. Revista de la facultad de Ciencias Médicas 72(2): 93-99.
Ferreira J, Hamui M, M, Torrents M, et al. The Influence of Chloride for the Interpretation of Plasma Bicarbonate during the Treatment of Diabetic Ketoacidosis. Pediatr Emerg Care. 2017 Jul 24.
Abbas Q, Arbab S, Haque A, et al. Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit. Pak J Med Sci. 2018 Jan-Feb;34(1):106-109
La revista no retiene los derechos de reproducción (copyright) por lo que los autores pueden volver a publicar sus trabajos con la sola mención a la fuente original de publicación.