Capnography during sedation/analgesia in the pediatric emergency department

OBJECTIVE: To measure changes in end-tidal carbon dioxide levels (ETCO2) during sedation/analgesia in pediatric patients and to describe ETCO2 changes associated with different sedation strategies. METHODS: This was a prospective, observational patient series in an urban pediatric emergency department (PED). Participants included 106 children with a mean age of 6.8 years. (range 1.2-16.6 years). Sedation/analgesia was given for fracture reduction (55%), laceration repair (37%), abscess incision and drainage (4%), and lumbar puncture (LP) (4%). Medications included fentanyl, morphine, ketamine, and midazolam. Continuous ETCO2 waveforms were recorded via a Capnogard ETCO2 Monitor. Oxygen saturation was recorded using a Nelcor N-200 pulse oximeter. Recording began prior to sedation and continued until the patient was awake or when it was necessary to remove the patient from the monitor for further medical care. Each record was analyzed for peak ETCO2 and averaged over five consecutive breaths, before and after the administration of medications. The main outcome measure was the change in ETCO2 levels. RESULTS: The mean increase in ETCO2 was 6.7 mmHg (P is included in, 0.00001; range: +0.16 to +22.3). ETCO2 increased by 3.2 mmHg (95% CI = 2.2-4.2) for midazolam alone, 5.4 mmHg (95% CI = 4.5-6.4) for midazolam and ketamine, and 8.8 mmHg (95% CI = 7.4-10.2) for midazolam and opiate. Two patients had transient SpO2 desaturations below 93%, which corrected with stimulation. CONCLUSIONS: Commonly used agents for pediatric sedation result in significant increases in ETCO2. ETCO2 is a useful adjunct in assessing ventilation and may serve as an objective research tool for assessing different sedation strategies.     

Continuous non-invasive end-tidal CO2 monitoring in pediatric inpatients with diabetic ketoacidosis

INTRODUCTION: Pediatric inpatients with diabetic ketoacidosis (DKA) are routinely subjected to frequent blood draws in order to closely monitor degree of acidosis and response to therapy. The typical level of acidosis monitoring is less than ideal, however, because of the high cost and invasiveness of frequent blood labs. Previous studies have validated end-tidal carbon dioxide (EtCO2) monitoring in the emergency department (ED) for varying periods of time. We extend these findings to the inpatient portion of the hospitalization during which the majority of blood tests are sent. METHODS: All patients admitted to an intermediate care unit in (InCU) a large children's hospital were fitted with an appropriately sized oral/nasal cannula capable of sensing EtCO2. Laboratory studies were obtained according to hospital clinical practice guidelines. In a retrospective analysis, EtCO2 values were correlated with serum total CO2 (stCO2), venous pH (vpH), venous pCO2 (vpCO2), and calculated bicarbonate from venous blood gas (vHCO3-). RESULTS: A total of 78 consecutive episodes of DKA in 72 patients aged 1-21 yr were monitored for 3-38 h with both capnography and laboratory testing, producing 334 comparisons. Initial values were as follows, reported as median (range): stCO2, 11 (4-22) mmol/L; vpH, 7.281 (6.998-7.441); vpCO2, 28.85 (9.3-43.3) mmHg; and vHCO3-, 14 (3-25) mmol/L. EtCO2 was correlated well with stCO2 (r = 0.84, p < 0.001), vHCO3- (r = 0.84, p < 0.001), and vpCO2 (r = 0.79, p < 0.001). CONCLUSIONS: These data support the findings of previous studies limited to ED populations and suggest that non-invasive EtCO2 monitoring is a valuable and reliable tool to continuously follow acidosis in the setting of the acutely ill pediatric patient with DKA. Continuous EtCO2 monitoring offers the practitioner an early warning system for unexpected changes in acidosis that augments the utility of intermittent blood gas determinations.     

1型糖尿病并低三碘甲状腺氨酸综合征201例

目的探讨1型糖尿病(T1DM)及糖尿病酮症酸中毒(DKA)患儿并低三碘甲状腺氨酸(T3)综合征的临床特点。方法采用放射免疫分析法检测91例T1DM并DKA患儿(DKA组)及110例单纯T1DM患儿(非DKA组)血清T3、甲状腺素(T4)、促甲状腺激素(TSH)水平,观察2组T3、T4下降例数及水平,并将DKA组分为轻、中、重3个亚组,观察不同组别中甲状腺激素变化特点。结果 DKA组易发生T3、T4下降,DKA组T3[(0.54±0.51)μg.L-1]、T4[(5.65±2.80)μg.L-1]与非DKA组T3[(1.02±0.38)μg.L-1]、T4[(9.28±2.85)μg.L-1]比较,差异均有统计学意义(Pa<0.000 1)。中、重度DKA组与非DKA组T3比较,差异有统计学意义(Pa<0.000 1),轻、中、重度DKA组与非DKA组T4比较,差异均有统计学意义(Pa<0.000 4,0.000 1)。DKA组与非DKA组TSH比较,差异无统计学意义(P>0.05)。结论 T1DM患儿甲状腺激素检测的结果主要表现为T3降低,部分伴T4降低,其疾病的严重程度与甲状腺激素降低程度一致,T1DM并DKA患儿的T3、T4水平均有明显下降,提示T1DM患儿需重视甲状腺激素的检测,利于早期防治。     

1型糖尿病酮症酸中毒患儿缺氧诱导因子-1α与血管内皮细胞生长因子mRNA表达水平的变化

目的探讨1型糖尿病(T1DM)酮症酸中毒(DKA)患儿缺氧诱导因子-1α(HIF-1α)与血管内皮细胞生长因子(VEGF)mRNA水平的变化。方法天津市儿童医院住院T1DM并DKA患儿30例,于确诊24 h内(DKA 1组)及DKA纠正后10 d(DKA 2组)采血,另选取同期住院的不伴感染、缺氧、肿瘤或结缔组织病的同年龄同性别患儿30例为对照组。实时荧光定量PCR(Real-time PCR)法测定其外周血CD4+T淋巴细胞HIF-1α与VEGF mRNA的相对表达水平。PCR产物行琼脂糖凝胶电泳鉴定特异性。采用SPSS 13.0软件进行统计学分析。结果 3组HIF-1α及VEGF mRNA相对表达水平比较差异均有统计学意义(Pa<0.01)。DKA1组HIF-1α及VEGF水平明显高于对照组,差异有统计学意义(Pa<0.01);DKA纠正后HIF-1α及VEGF水平恢复,差异有统计学意义(P<0.05,0.01),但直至DKA纠正后10 d(DKA2组)仍未恢复至对照组水平,差异有统计学意义(P<0.01,0.05)。Real-timePCR产物行琼脂糖凝胶电泳,产物位于预期位置,确定产物特异性。结论 T1DM并DKA患儿CD4+T淋巴细胞HIF-1α与VEGFmRNA水平升高,且DKA纠正后HIF-1α与VEGF mRNA水平不能恢复至正常,这可能与T1DM并发症的发生发展有关。     

Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus

OBJECTIVES: (a) To determine the incidence and severity of diabetic ketoacidosis (DKA) and (b) to stratify according to insurance status at the initial diagnosis of type 1 diabetes (T1DM). RESEARCH DESIGN AND METHODS: Subjects included children <18 yr who presented with new-onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. Insurance status and initial venous pH were obtained. RESULTS: Overall, 383 subjects presented with new-onset T1DM and 359 (93.7%) were enrolled. Forty-three (12.0%) of these children were uninsured and 40 (11.1%) had Medicaid. One hundred and two (28.4%) subjects presented with DKA. When compared to the insured subjects, uninsured subjects had a significantly increased risk of presenting with DKA [odds ratios (OR): 6.19, 95% CI 3.04-12.60, p < 0.0001], as well as presenting with severe DKA, defined as venous pH <7.10 (OR: 6.09, 95% CI 3.21-11.56, p < 0.0001). There were no differences, however, between the insured and Medicaid subjects in their probability of presenting with DKA or severe DKA. The risk of presenting with DKA (as well as with severe DKA) was the highest among patients <4 yr old. CONCLUSIONS: At the time of initial diagnosis, uninsured patients were more likely to present with DKA than insured patients. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening. A potential explanation is that uninsured subjects may delay seeking timely medical care, thereby presenting more critically ill, whereas insured subjects may have their T1DM diagnosed earlier.     

5岁以下1型糖尿病患儿21例

目的探讨5岁以下婴幼儿糖尿病的临床特点、诊断及酮症酸中毒(DKA)的抢救措施。方法回顾性分析21例5岁以下婴幼儿糖尿病患儿的发病情况、临床特点、误诊情况,并探讨急救治疗体会。结果婴幼儿糖尿病临床症状不典型,糖尿病自身抗体阳性率低,初诊误诊率达52.4%,DKA发生率也高达52.4%。感染是诱发DKA的常见原因,患儿无1例死亡,1例放弃治疗,出院后治疗依从性不一。结论婴幼儿糖尿病多为特发性,临床症状不典型,易误诊、漏诊。感染可能导致患儿糖尿病的进展和临床表现出现。小剂量胰岛素持续静滴、调节酸碱平衡和纠正电解质紊乱是急救的关键。     

Serum interleukin-18 levels are raised in diabetic ketoacidosis in Chinese children with type 1 diabetes mellitus

OBJECTIVE: To investigate the role of serum interleukin (IL-18) in children with type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis (DKA). DESIGN: Case-control study. SUBJECTS: Sixty-one children with T1DM including 28 with DKA and 33 without DKA and 30 age - and sex-matched healthy controls were recruited. METHODS: Serum IL-18, IL-12, and IFN-gamma levels were measured in all subjects by enzyme linked immunosorbent assay. RESULTS: Serum IL-18 levels were significantly higher in patients with DKA than those in patients without DKA (759.2 +/- 353.8 pg/mL vs. 634.9 +/- 399.7 pg/mL, P = 0.001) and healthy controls (310.0 +/- 265.3 pg/mL). The serum IL-12 and IFN-gamma levels were not different between patients and controls (277.5 +/- 207 pg/mL vs. 351.4 +/- 223.4 pg/mL, P = 0.45 and 7.02 +/- 7.53 pg/mL vs. 5.59 +/- 5.34 pg/mL, P = 0.21, respectively). CONCLUSION: Serum IL-18 levels are increased in children with type 1 diabetes mellitus and could be a predictor of diabetic ketoacidosis.     

Prevalence and characteristics of type 2 diabetes mellitus in 9-18 year-old children with diabetic ketoacidosis

OBJECTIVE: To estimate the prevalence of type 2 diabetes mellitus (DM2) in 9-18 year-old children with diabetic ketoacidosis (DKA) and to describe the presenting biochemical characteristics and response to standardized DKA treatment. METHODS: Data were collected from a consecutive sample of 9-18 year-old children presenting with DKA. DKA was defined as hyperglycemia and ketosis with an initial pH <7.3, or bicarbonate <15 mmol/l. Patients were classified as having DM2 if they had negative autoantibody status and normal or elevated fasting C-peptide. RESULTS: The prevalence of DM2 in patients with DKA was 13.0% (6.1-23.3%). There was no significant difference in the presenting pH (7.14 vs 7.15), but blood glucose was higher (735 vs 587 mg/dl) in patients with DM2, than in patients with type 1 DM (DM1). The duration of insulin infusion until resolution of acidosis (17.3 vs 13.2 h) and intensive care unit stay (2.4 vs 1.6 days) were longer in patients with DM2. Seven of the nine patients with DM2 did not require insulin at 1-year follow-up. CONCLUSIONS: Children with DM2 can present with DKA and constitute a significant percentage in the above 9-year age group. The need for insulin must be carefully re-evaluated as DKA resolves in these patients. Adolescents with DM2 and their families need to be educated about DKA.     

已确诊的1型糖尿病患儿病程中酮症酸中毒发生情况及诱因调查

目的 调查已确诊的1型糖尿病（T1DM）患儿病程中糖尿病酮症酸中毒（DKA）的发生情况。方法 以首都医科大学附属北京儿童医院、上海交通大学附属儿童医院、南京医科大学附属南京儿童医院、郑州市儿童医院、江西省儿童医院、西安交通大学第一附属医院、昆明医科大学第一附属医院、武汉市妇女儿童医疗保健中心、苏州大学附属儿童医院、聊城儿童医院、福建省福州儿童医院、成都市妇女儿童中心医院12家医院登记系统为基础调查多中心1995年12月至2014年6月胰岛素治疗下的已确诊T1DM患者病程中发生DKA的频度和诱发原因。其中,T1DM确诊后发生的第1次DKA为组1A,第2次DKA为组1B。选择北京儿童医院2011年12月-至2012年5月T1DM患者血糖控制状况横断面调查病程中无DKA发生者为对照组,即组2。结果 12家医院共新诊断了1676例T1DM患儿,其中89例患者在病程中发生了100次DKA,发生比率为5.3%（89/1676）,发生频率为5.9%（100/1676）。且各中心的DKA发生比率不同,波动在1.1%～24.1%之间。组1A的糖化血红蛋白（HbA1c）［（11.31±3.03）% vs.（8.26±1.53）%,P＜0.01］及胰岛素剂量［（0.85±0.42）IU vs.（ 0.71±0.31）IU,P＜0.01］明显高于组2。组1A的胰岛素泵使用率高于组2（25.0% vs. 11.2%,P＝0.01）。而且,前者的自我血糖监测达标率（12.1% vs. 40.1%, P＜0.01）及复诊次数达标率（21.2% vs. 46.6%,P＜0.01）明显低于后者。组1A的DKA诱因主要是感染（33.7%）、中断胰岛素注射（21.3%）、饮食异常（20.2%）,1例患者为胰岛干细胞移植后DKA。组1B仍以感染为主要诱因（4/10）,1例患者因为胰岛素泵故障而发生DKA（1/10）。不同病程内发生的DKA诱因分布不同（P＜0.01）,1年内主要以中断胰岛素注射为主,占39.3%（11/28）;1年以上中断胰岛素注射仅占13.1%（8/61）,主要以感染（22/61）和饮食异常（16/61）为诱因。DKA发生率高的医院主要是以感染为诱因,达50%（12/24）,而DKA发生率低的医院感染诱因占28.1%（18/64）（P＜0.01）。结论 已确诊T1DM患者病程中DKA发生率为5.3%,各中心不同,最高达24.1%。DKA者的血糖控制水平差,不能规律的进行自我血糖监测及门诊复诊,应该强化糖尿病教育。胰岛素泵使用者及胰岛干细胞移植的患者成为新的教育关注点。DKA发生率高的医院需要强化患者学习感染时的处理措施。     

��ȷ���1�����򲡻���������֢ͪ���ж�����������������

??Abstract?? Objective To investigate the occurrance of DKA in established T1DM children. Methods According to the registration system in the following-hospitals??Beijing Children’s Hospital of Capital Medical University?? Children’s Hospital of Shanghai?? Nanjing Children’s Hospital??Children’s Hospital of Zhengzhou?? Children’s Hospital of Jiangxi?? the First Affiliated Hospital of Xi’an Jiaotong University??First Affiliated Hospital of Kunming Medical University?? Children’s Hospital of Wuhan?? SooChow University Affiliated Children’s Hospital?? Children’s Hospital of Liaocheng?? Children’s Hospital of Fuzhou?? Chengdu Women & Children’s Central Hospital???? we investigated the frequency and cause of DKA in children with established T1DM from December 1995 to June 2014. After the diagnosis of T1DM?? the first time DKA was for group 1A?? the second DKA for group 1B. We conducted a cross-sectional survey of blood glucose control status for patients with T1DM from December 2011 to May 2012 in Beijing Children’s Hospital. Patients who did not have DKA episode in the course of T1DM were selected as control group ??group 2??. Results Totally 1676 children were newly diagnosed with T1DM by 12 hospitals?? and 89 patients occurred 100 DKA after T1DM diagnosed. The incidence and frequency of DKA was 5.3% ??89/1676?? and 5.9% ??100/1676??. The frequency was different in 12 hospitals?? fluctuating between 1.1% and 24.1%. Compared with group 2?? group 1A had high level of HbA1c ???11.31±3.03??% vs. ??8.26±1.53??%?? P??0.01?? and insulin dosage ???0.85±0.42?? IU vs. ??0.71±0.31?? IU?? P??0.01??. There were more patients with insulin bump in group 1A than group2 ??25.0% vs. 11.2%?? P??0.01???? and few patients reached the standard of blood glucose monitoring ??12.1% vs.40.1%?? P??0.01?? and follow-up ??21.2% vs. 46.6%?? P??0.01??. The main reasons of DKA in group 1A were infection ??33.7%???? interrupting insulin therapy ??21.3%?? and eating disorder ??20.2%???? one patient had DKA after islet stem cell transplantation. Infection was also the major cause of DKA in group 1B ??4/10???? and 1 patient had DKA because of insulin bump failure. For DKA which occurred within different course?? the distribution of causes was different ??P??0.01??. Within 1 year of T1DM duration?? the major reason was interrupting insulin injection ??39.3%??. For patients more than 1 year?? it only accounted for 13.1%??8/61???? the major causes were infection ??22/61?? and eating disorder ??16/61??. The major cause in mutiple hospitals with high DKA frequency was infection ??50.0%???? while in other hospitals 28.1% of patients had DKA because of infection ??P??0.01??. Conclusion The frequency of DKA is 5.3%?? which is different in 12 hospitals?? with the highest up to 24.1%. Patients with DKA have poor glycemic control?? and they can not regularly monitor blood glucose and follow-up. We should emphasize the education of diabetes. Patients with insulin pump and islet stem cell transplantation must also become a new focus of education. Hospitals with high DKA frequency should give patients information how to deal with other diseases.     

交感神经皮肤反应在糖尿病患儿周围神经病早期诊断中的应用

目的探讨交感神经皮肤反应(SSR)在儿童糖尿病周围神经病交感神经纤维病变早期诊断的应用价值。方法对35例1型糖尿病(T1DM)儿童和30例健康儿童四肢分别进行电刺激SSR检测,测量每个肢体的平均起始潜伏期和峰-峰波幅,并比较2组各肢体的SSR起始潜伏期及峰-峰波幅差异。同时对T1DM组儿童进行神经传导速度(NCV)的检测,并对NCV检测异常率与SSR检测异常率进行比较。另外,还对有酮症酸中毒(DKA)史和无DKA史的2组患儿SSR检测异常结果进行比较。结果 T1DM组患儿各肢体SSR起始潜伏期均较健康对照组明显延长(Pa<0.05)。健康对照组30例四肢均可引出SSR波形,T1DM组31例患儿四肢均可引出SSR波形;4例患儿至少有一肢不能引出SSR波形(11.4%),其中2例患儿四肢均未引出SSR波形(5.7%);21例(60%)患儿至少有一肢SSR缺失或起始潜伏期异常,其中15例(71.4%)有DKA史,高于无DKA患儿异常检出率(6例,42.9%),但2组比较无统计学差异。T1DM组患儿NCV检测异常10例(28.6%),较SSR起始潜伏期的检出异常率低,两者比较差异无统计学意义(P>0.05)。结论 SSR检测可早期发现糖尿病周围神经病交感神经小纤维病变,较NCV敏感。     

25-羟维生素D与儿童1型糖尿病及酮症酸中毒的相关性研究

目的探讨血清25-羟维生素D[25-(OH)D]水平与儿童1型糖尿病(T1DM)及酮症酸中毒(DKA)的相关性。方法选取2006年1月—2009年12月期间152例住院患儿,其中52例为首次发病的T1DM患儿,包括酮症酸中毒(DKA组)21例,以及非酮症酸中毒(非DKA组)31例,其余100例为非T1DM组。检测并比较三组患儿的血清25-(OH)D水平,分析血清25-(OH)D水平与儿童T1DM及DKA的相关性。结果 DKA组患儿的血清25-(OH)D平均为(53.6±27.8)nmol/L,显著低于非DKA组的(69.7±27.9)nmol/L和非T1DM组的(81.8±28.3)nmol/L(P<0.05);非DKA组患儿的血清25-(OH)D水平显著低于非T1DM组(P<0.05)。结论 T1DM患儿的血清25-(OH)D水平低,尤以DKA患儿最为明显,维生素D在儿童T1DM发病中的潜在保护效应值得关注。     

End-tidal carbon dioxide monitoring during sedation with a combination of midazolam and ketamine for children undergoing painful, invasive procedures.

BACKGROUND: Previous studies evaluating the respiratory effects of sedation regimens have focused on events such as a decline in O2 saturation or apnea. The current study used both end-tidal carbon dioxide (ETCO2) monitoring and pulse oximetry to evaluate the respiratory effects of midazolam and ketamine. METHODS: Fifty children who required sedation during invasive procedures formed the cohort for the study. During sedation, ETCO2 was sampled from nasal cannulae of spontaneously breathing patients and measured by a side-stream aspirating infrared device. RESULTS: During the procedure, O2 saturation decreased by 3% or more in three patients. Supplemental oxygen at 2 liters per minute was administered to these patients. The lowest oxygen saturation was 84%. During the total of 767 minutes of monitoring, there were 3068 ETCO2 values recorded. The high ETCO2 values ranged from 37 to 53 mmHg (40.5 +/- 3.3 mmHg). Ninety percent, or 2760, of the values were 40 mmHg or less, 7% or 214 were between 41 and 45 mmHg, 3% or 92 were between 46 and 49 mmHg, and 2 isolated values were greater than 50 mmHg. One episode of airway obstruction was identified by noting cessation of the ETCO2 waveform. This was relieved by repositioning the patient's airway. The three episodes of O2 desaturation, two ETCO2 values greater than 50 mmHg, and the episode of upper airway obstruction all occurred in three patients. Two of these patients had trisomy 21 with macroglossia, and the third had had a recent upper respiratory infection and a history of tonsillar hypertrophy. CONCLUSION: The incidence of adverse cardiorespiratory events associated with the current sedation regimen of midazolam-ketamine is lower than that reported with other commonly used regimens. The addition of ETCO2 monitoring provides an additional monitor to allow for early detection of airway obstruction or subclinical degrees of respiratory depression.     

儿童 1型糖尿病 30年临床特征及随访观察

目的 分析儿童1型糖尿病（T1DM）的临床特征,探讨该病对儿童生长发育的影响程度及后期并发症发生的情况。方法 对发病年龄在13个月至14．7岁,经实验室检查确诊为T1DM的210例患儿的临床特征进行了回顾性分性,并对99例患儿进行了1～24年的并发症、生长发育、死因随访。结果 因单纯糖尿病人院者47例（22．4％）;伴酮血症入院者69例（32．9％）;伴酮症酸中毒入院者94例（44．7％）,其中农村患儿78例。起病时有诱因者43例,其中自停胰岛素15例。酮症酸中毒患儿住院时间明显比单纯糖尿病患儿长（P〈0．05）。随访的99例中出现各种并发症50例,其中以微血管病变发生率最高。病程长易并发各种并发症（P〈0．05）,病后的监测方法与并发症的发生也明显相关。患儿组身高明显低于对照组（P〈0．05）。结论 酮症酸中毒是儿童糖尿病的基本特征;病程长易并发各种并发症;加强对儿童糖尿病患者的血糖检测和病后教育,将对儿童糖尿病的治疗起重要作用。     

Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics

Abdul‐Rasoul M, Al‐Mahdi M, Al‐Qattan H, Al‐Tarkait N, Alkhouly M, Al‐Safi R, Al‐Shawaf F, Mahmoud H. Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics. Background: Diabetic ketoacidosis (DKA) has significant morbidity and mortality, and is common at diagnosis in children. Objective: Describe the frequency and severity of DKA at diagnosis of type 1 diabetes mellitus (T1DM) in children in Kuwait. Methods: Hospital records of 677 diabetic children less than 12 yr of age, diagnosed during the period of 2000–2006 were reviewed. DKA was defined as blood glucose > 11 mmol/L, pH < 7.3, and/or bicarbonate < 15 mmol/L with ketonuria. Results: Of all patients diagnosed with T1DM, 255 (37.7%) presented with DKA. The frequency of DKA was constant between 2000 and 2002 (42.7–41.5%), but decreased in the following years to 30.7% in 2006 (p < 0.005). The majority had either mild or moderate DKA (74.1%). Fifty‐one (36.7%) of all children in the 0–4 yr had severe DKA compared to ten (2.9%) in the 5‐ to 8‐yr‐old group, and three (1.5%) in 9‐ to 12‐yr‐old patients (p < 0.0001). Moreover, 83% of children with severe DKA were in the 0–4 yr age group. One child (0.15%) died and twenty‐seven (4%) needed intensive care unit (ICU) care. Conclusion: Our study provides recent data on Middle Eastern population, for whom data are sparse. Although it has significantly decreased, the frequency of DKA at presentation of T1DM in children in Kuwait is still high, secondary to the high prevalence of diabetes in the community. Young children, especially those less than 2 yr old remain at high risk. Increasing the general awareness of the public as well as of pediatricians to the disease may lead to early diagnosis before the development of acidosis.     

儿童糖尿病198例

目的 探讨儿童糖尿病(DM)的临床特点,为临床诊治提供理论依据.方法 对1999年1月-2009年3月在本院住院的198例DM患儿的临床表现和实验室检查进行回顾性临床分析.结果 198例DM患儿中,男97例,女101例.均为首诊病例;发病高峰年龄为5～6岁及9～11岁;首诊例数逐年增加,2008年较1999年增加了3.7倍;其中1型糖尿病(T1DM) 174例(占88.9％),2型糖尿病7例(占3.5％),新生儿DM 14例(占7.1％),其他3例(占1.5％).首诊的TlDM患者中,酮症酸中毒(DKA)的发生率为42.0％;发病前有感染史者55例,与无感染史者比较,DKA的发生率有统计学差异(P＜0.01).有DM家族遗传史者23例.并甲状腺功能亢进症2例;并暂时性甲状腺功能减低症31例;并肝功能异常30例,肾功能异常12例,血脂异常48例,尿蛋白阳性27例.糖化血红蛋白为(12.0±1.8)％;共分析了25例T1 DM患者的自身抗体,胰岛细胞抗体阳性率为28％,胰岛素自身抗体的阳性率为20％,谷氮酸脱羧酶自身抗体(GADA)阳性率为72％.结论 首诊的儿童DM逐年增加,以T1DM为主;新生儿DM增加明显;DKA是T1DM患者就诊的重要原因;首诊的T1DM者中,感染是发生DKA的重要诱因;儿童DM常合并暂时性甲状腺功能减低症、肝肾功能异常及血脂异常;糖尿病自身抗体中GADA的阳性率最高.     

Difficulties or mistakes in diagnosing type 1 diabetes in children?—demographic factors influencing delayed diagnosis

Background: Diabetic ketoacidosis (DKA) development in children with new‐onset type 1 diabetes (T1DM) is often the main consequence of delayed diagnosis. The aim of the study was to estimate the frequency of difficulties in T1DM diagnosis and to investigate if and how the demographic factors (gender, patient's age at presentation, family history of T1DM, level of maternal education, place of residence, and health service unit the patient called at) have any influence on diagnostic delays. Subjects and methods: Retrospective analysis of 474 children (243 boys—51.27% and 231 girls ?48.73%) with new‐onset T1DM aged below 17 yr and living in the Pomeranian region of Poland was carried out. The delay in diagnosis was recognized if the patient was not diagnosed on the first visit because of omission, wrong interpretation of main diabetic symptoms, exclusive treatment of additional signs, or concomitant diseases. Results: Difficulties in diagnosing T1DM were found in 67 cases (14.13%) and they are the main cause of DKA development in these children (p = 0.00). Among the examined demographic factors, mainly the patient's age at presentation has a significant influence on diagnostic delays (p = 0.01), especially in children below 2 yr (p = 0.00). Most frequently family doctors were responsible for wrong preliminary diagnosis. Conclusions: Difficulties in diagnosing T1DM are a significant cause of DKA development in children with new‐onset disease. Patient's age at presentation is the main risk factor of delayed diagnosis, especially in children below 2 yr. The increase in awareness among pediatricians concerning the possibility of T1DM development in children is needed.     

Capnography as a rapid assessment and triage tool for chemical terrorism

The assessment and triage of victims of chemical terrorism in the emergency department and the prehospital setting has become an important priority. This article proposes the use of capnography as a prehospital assessment and triage tool for monitoring victims of chemical terrorism and for critically ill patients. Capnography provides the ABCs in less than 15 seconds and identifies the common complications of chemical terrorism. Further, the reliability of capnography is not affected by motion artifact or low perfusion and it is accurate and reliable in actively seizing patients. Emergency departments and emergency medical services systems should consider adding capnography to their chemical terrorism education and training.     

Changing spectrum of diabetes mellitus in children: challenges with initial classification

Objective. To determine the frequency of initial misclassification of diabetes mellitus (DM) in children and to compare the presenting features of DM1, DM2, and the misclassified cases. Results. A total of 206 patients fulfilled the inclusion criteria. Of them, 74.75% had DM1 and 25.25% had DM2. Ten percent of studied patients had a subsequent change in classification. The mean HbA1c of the DM2 patients, who were initially misclassified, was 13.35% (SD = 1.96). The mean HbA1c of DM2 patients with correct initial classification was 8.83% (SD = 3.01). Diabetes ketoacidosis (DKA) was seen in 59.44% of DM1 and 23.91% of DM2 patients. Of the DM2 patients who were initially misclassified, 58.82% had presented in DKA as opposed to only 6.45% of patients who were correctly classified. Conclusion. The initial classification of DM frequently requires revision (10% in this study). The misclassification is highest among DM2 patients who initially present with higher HbA1c and DKA.     

Delayed diagnosis in type 1 diabetes mellitus

Children with suspected type 1 diabetes mellitus (T1DM) should have same day referral to a paediatric diabetes team. 99 children (54 male; median age 10.5 years, range 0.9-15.9 years) were diagnosed with T1DM at our hospital between January 2004 and June 2007. 27 (27.2%) presented in diabetic ketoacidosis (DKA). 37 (37.3%) required hospital admission, while the rest had ambulatory management. In 21 (21.2%) children, diagnosis was delayed >24 h (median 3.0 days, range 1-14 days) due to missed diagnosis at the local hospital (four) or by the general practitioner (seven), arranging a fasting blood glucose test (nine) and outpatient appointment requested via fax (one). Children with delayed diagnosis presented more frequently in DKA (52.3% vs 20.5%, p<0.01), with a higher median presenting HbA1c (12.3% vs 10.9%, p<0.05). There were no differences in age and sex between the delayed diagnosis and immediate referral groups. Healthcare providers need to be aware of the importance of immediate referral of children newly diagnosed with T1DM.