- The Washington Times - Monday, August 23, 2004

Two doctors have developed new guidelines to help hospital workers recognize earlier a rare swelling of the brain that is the most common cause of death for diabetic children.

The endocrinologists have identified a combination of symptoms most likely to indicate the earliest onset of cerebral edema, brain swelling, creating a screening method that was 96 percent accurate in their study.

“We should be able to save 90 percent of these kids by using the guidelines,” which advise doctors and nurses about symptoms in children likely to develop the brain swelling, said Dr. Arlan Rosenbloom, a pediatric endocrinologist at Shands Hospital at the University of Florida and senior author of a report published in Diabetes Care, a journal of the American Diabetes Association.

The symptoms, which were incorporated in a bedside screening regimen that was used to evaluate patients, included a slowing of heart rate, changes in consciousness and mental status, incontinence, vomiting after hospitalization, headache, or lethargy.

“Kids with diabetes generally don’t die, but when they do, it is primarily because of cerebral edema, and the traditional thinking has been physicians can’t do a lot if this occurs,” said Dr. Andrew Muir, chief of pediatric endocrinology at the Medical College of Georgia and lead author of the report.

Cerebral edema occurs in about one of every 100 pediatric episodes of a life-threatening condition in diabetics known as ketoacidosis. Untreated, the diabetic lacks sufficient insulin to process glucose and acidic substances called ketones, and his body begins breaking down fats for energy. Excess sugar and ketones accumulate in the bloodstream.

When cerebral edema develops in youngsters with ketoacidosis, Dr. Rosenbloom said, it rapidly can cause severe brain damage or death.

“There is 25 percent mortality, and another one-third of victims suffer permanent brain damage,” he said, noting that cerebral edema is almost exclusively a disorder of diabetic children.

“There have been only a few cases involving patients over the age of 21,” he said.

Dr. Rosenbloom and Dr. Muir conducted their investigation when they were at the University of Florida at Gainesville. They reviewed medical records of 24 patients, ages 1 to 15, who developed cerebral edema as a result of ketoacidosis and were treated at hospitals nationwide. Dr. Rosenbloom said all the patients “had poor outcomes,” and their cases were in litigation.

Records from two other patients seen at Shands Hospital also were reviewed. In addition, the researchers analyzed 69 consecutive episodes of diabetic ketoacidosis in children treated at Shands who were not thought to have cerebral edema.

Dr. Muir said the study suggests that cerebral edema is a “complication that often progresses slowly at first.” However, he said, the “rate of deterioration becomes more rapid with time, and, in later stages it’s very hard to arrest.”

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