suspected cerebral edema in diabetic ketoacidosis carmen l. soto-rivera资料.pdf

该【suspected cerebral edema in diabetic ketoacidosis carmen l. soto-rivera资料 】是由【李十儿】上传分享，文档一共【6】页，该文档可以免费在线阅读，需要了解更多关于【suspected cerebral edema in diabetic ketoacidosis carmen l. soto-rivera资料 】的内容，可以使用淘豆网的站内搜索功能，选择自己适合的文档，以下文字是截取该文章内的部分文字，如需要获得完整电子版，请下载此文档到您的设备，方便您编辑和打印。:IsThereStillaRoleforHead1529-7535CTinTreatmentDecisions?*-Rivera,MD1,2;,MS3;,MD1,2;,MD,MPH1Soto-RiveraetalObjectives:NeurologicdeteriorationassociatedwithcerebralMeasurementsandMainResults:Alteredmentalstatuswasedemaindiabeticketoacidosisistypicallysuddeninonset,pro-documentedduring96of686diabeticketoacidosisadmissionsgressesrapidly,(14%).Comparedwithalertpatients,thosewithalteredmentalbrainimagingbyheadCTindecisionstotreatforcerebraledemastatuswereyounger(median,;p=)(pH,;p<),withhigherserumtodescribethecharacteristicsofpediatricpatientswithdiabeticosmolality(328vs315mOsm/kg;p<)andlongerhos-ketoacidosiswhodevelopalteredmentalstatusandevaluatethepitallengthofstay(;p=).HeadCTwasper-:Retrospectiveanalysisofclinical,biochemical,andradio-alteredmentalstatus(63%),16(27%)-Setting:Tertiarycarechildren’shospital(2004–2010).ing23ofthe60admissions(38%),duringwhich12(52%)hadPatients:Sixhundredeighty-sixadmissionsofpatients(<26yr)normalheadCTresults,eightofthese12(67%)(33%):-apy,fourheadCTscan(36%)occurredafterhyperosmolartreat-mentandseven(64%)*,therewasamedian2-hour1DivisionofMedicineCriticalCare,DepartmentofMedicine,BostonChildren’sHospitalandHarvardMedicalSchool,Boston,,DepartmentofMedicine,BostonChildren’sConclusions:Inthissingle-centerretrospectivestudy,therewasnoHospitalandHarvardMedicalSchool,Boston,,BostonChildren’sHospital,Boston,-headCT,andheadCTmayhaveledtoasignificantdelayinhyper-xxxtionsappearintheprintedtextandareprovidedintheHTMLandPDFosmolartherapy.(PediatrCritCareMed2017;18:207–212)versionsofthisarticleonthejournal’swebsite(http://journals./pccmjournal).KeyWords:puterizedtomography;diabeticMarchResearchreportedinthispublicationwassupportedbytheNationalInsti-ketoacidosistutesofHealth(T32HD75727-1).,management,analysis,andinterpretationofthedata;norpreparation,review,(DKA)-plicationoftype1diabetesmellitusInstitutesofHealth(NIH).(T1DM)ursin25–40%ofchildrenwiththisresearchfromtheNIHandherinstitutionreceivedfundingfromtheD3NationalResearchServiceAwardTrainingGrant(T32HD75727-1)anddisease(1).MentalstatusabnormalitiesarereportedinuptofromAgencyforHealthcareResearchandQuality-fundedTrainingGrant15%ofchildrenwithDKA(2,3)andhavebeenassociatedwith2017(K12HS022986-01).Theremainingauthorshavedisclosedthattheyevidenceofcerebraledema(CE)onMRI(4).,E-mail:carmen.******@-Copyright?(5)andisdefinedbyDOI:?-Riveraetalresponsestopain,decorticateposture,andabnormalneuro-signs,aScale(GCS)score,nursingandphysiciangenicrespiratorypatterns(6).Althoughrare,withareportedclinicalnotes,laboratoryvalues,–4%(1–3,7–9),EinDKAisaPatientswereclassifiedashavingAMSbasedonnursingandlife-–24%(1,8,10)andisassociatedwithaneurologicsymptomscore,accordingtopreviouslypublishedrapidneurologicdeteriorationrequiringemergenttreatmentliterature(16),basedondescriptionsofthepatient’sclinicalsta-(11).CurrentclinicalpracticeguidelinesforDKAfocusontusinclinicalnotes(attendingphysician,resident,and/ornurs-rapidclinicalrecognitionandtreatmentofCEinDKA(5),withing)aswellasGCSscore(1=irritable,disoriented,confused,ormendedonly“aftertreatmentforcerebralGCS13–15;2=lethargic,CS11–12;3=stupor-edemahasbeenstarted,toruleoutotherpossibleintracere-ous,CS8–10;4=abnormalorCS6–7;and5=focalorhemorrhage,whichmaybenefitfromspecifictherapy”(5).neurologicfinding,fixedanddilatedpupil(s),respiratoryarrest,CS3–5)’,regardlessTheprimaryunitofanalysiswasDKAadmission(orDKAofneurologicsymptoms,havenarrowingofthelateralventriclesadmissionwithAMS),-therapy,ountedformultipleDKAadmissionspersetting(4).Ontheotherhand,upto40%ofchildrenwithclini-(6).,itposesrisksAMS,,aswellashaspotentiallyadverseeffectsofradiationinducedmalignancy,-especiallyonthegrowingchild(12–14).Inchildren15yearsandticregressionwasthenusedtofurtherevaluatetheassociationyounger,cumulativeionizingradiationdosesfromrepeatedheadofdemographicandclinicalvariableswiththeuseofheadCTinCTscanincreasestheriskofbraintumorsandleukemia(15).-Thediscordancebetweenimagingfindingsandclinicalpre-sion;gender;onsetofdiabetes;neurologicsymptomscore;ini-sentation,thecostandrisksassociatedwithexposuretounnec-tialpH,serumbicarbonate,bloodureanitrogen(BUN),glucose,essaryradiationandtheuncertainprevalenceofintracerebralandhemoglobinvalues;(AMS).-describethecharacteristicsofpatientswithDKAwhodevelopingadmission,-heroleofheadCTintreatmentdecisionssionswithbothheadCTandhyperosmolartherapyforCE,---mentofpatientswithDKAandsuspectedCEaremadebasedformedusingSAS(;SASInstitute,Cary,NC).uponclinicalfindings,,during96(14%)ofAllpatientswithanICD-9codeforDKA(,,)whichpatientsdevelopedAMS().Patientswhodevel-admittedtoBostonChildren’(median,;p=)(Table1).TherereviewedtoensurethatpatientshadadiagnosisofDKAdefinedwerenostatisticallysignificantdifferencesingenderorpreva-byaclinicalhistoryconsistentwithdiabetes,,patientswithAMSweresignificantlymoreaci-equalto15mmol/L,andmoderatetolargeketonuriaonaurinedoticwithlowerserumbicarbonateandhigherserumosmo-,bloodglucoselevels,andanionDKA,pharmacyrecordswerealsoobtainedforallpatientswhogap(allp<).Initialsodiumlevelsweresimilarbetweenreceived3%-referencedwithpatientswithDKAasdefined(paredwithalertpatients(median[(IQR)],[4–5]vs3[3–4];p=).Therewerenoreviewedanddemographicinformation,onsetofdiabetes,?Volume18?Number3Copyright?-formedduring68DKAadmissionsoverall(10%).Asexpected,patientswithAMSweremorelikelytoundergoheadimagingthanalertpatients(n=60[63%]vs8[1%];p<)(Table?1).AmongDKAadmissionswithAMS,therewerenostatisticallysignifcantdifferencesinpatient’sdemo-graphicsorclinicalsymptomsbetweenthosewhoreceivedheadimagingandthosewhodidnot,includingprevalenceofnewonsetdiabetes,initiallaboratoryvalues,andneedforintubation(Table2).Theneu-rologicsymptomscoreswerenotsignifcantlydifferentforpatientswithAMSwhounder-(DKA)admissionsbymentalstatuscategory,headCT(HCT),wentheadCTandthosewhoandtreatmentforcerebraledema(CE).AMS=alteredmentalstatus,tx=(n=96)Alert(n=590)paAgeatadmission,median(IQR),(–)(–),n(%)53(55)321(54),n(%)55(57)276(47)(fromoutsidehospitalorBostonChildren’sHospital),median(IQR)?(–)(–)<?P2,mmHg21(14–27)28(22–33)<?Sodium,mmol/L133(128–137)133(130–136)?Serumbicarbonate,mmol/L5(4–8)10(7–12)<?Bloodureanitrogen,mg/dL23(17–33)17(13–22)<?Glucose,mg/dL618(499–796)506(395–658)<?Aniongap,mmol/L30(26–34)27(23–30)<?Serumosmolarity,mOsm/kg328(311–348)315(305–328)<?Hemoglobin,g/(–)(–),n(%)4(4)0<,n(%)60(63)8(1)<,n(%)28(29)0<=parisonbetweengroupswerecalculatedusinglinearandlogisticregression,accountingformultipleadmissionsperpatientusinggeneralizedestimatingequationsforcontinuousandbinaryvariables,,<2%exceptforaniongap(87,alteredmentalstatus[AMS];411,alert),serumosmolarity(69,AMS;386,alert),andhemoglobin(95,AMS;449,alert).riticalCareMedicineCopyright?-(n=60)NoHeadCT(n=36)paAgeatadmission,median(IQR),(–)(–),n(%)33(55)20(56),n(%)34(57)21(58)