儿童糖尿病酮症酸中毒并发脑水肿临床分析

目的探讨儿童糖尿病酮症酸中毒并发脑水肿的临床特点及危险因素。方法对糖尿病酮症酸中毒并发脑水肿患儿的临床特点及病因进行分析,并与无脑水肿的患儿资料进行对比。结果在47例糖尿病酮症酸中毒患儿中,并发脑水肿4例（8.51%）,均为重度酮症酸中毒。与未并发脑水肿同等程度的酮症酸中毒患儿相比,并发脑水肿者在治疗期间血钠上升缓慢、甚至降低,尿素氮水平较高。4例患儿中有3例应用了碳酸氢盐,用量大于未并发组。结论糖尿病患儿并发重度酮症酸中毒时易并发脑水肿。血钠上升缓慢甚或降低、血尿素氮升高及碳酸氢盐的不适当应用,可增加脑水肿发生的危险。     

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目的探讨儿童糖尿病酮症酸中毒并发脑水肿的临床特征及危险因素。方法对重庆医科大学附属儿童医院1993—2005年住院治疗的糖尿病酮症酸中毒并发脑水肿患儿的临床特征及病因进行分析,并与未并发者进行对照比较。结果在71例酮症酸中毒患儿中,有6例临床表现符合脑水肿的诊断标准,临床确定为并发脑水肿,并发率为8·4%。6例均为重型酮症酸中毒。与未发生脑水肿同等程度的重型酮症酸中毒患儿相比较,并发脑水肿患儿酸中毒更为严重,在治疗期间血钠上升缓慢及持续低钠血症,尿素氮水平升高。6例患儿中有5例应用碳酸氢盐治疗,用量大于未并发者。结论糖尿病儿童并发重型酮症酸中毒易发生脑水肿。严重酸中毒、血钠上升缓慢或持续低钠血症、血尿素氮升高及碳酸氢盐的使用有可能增加脑水肿发生的危险性。     

儿童糖尿病酮症酸中毒的急救

酮症酸中毒是儿童糖尿病最重要的并发症,也是糖尿病患儿死亡的主要原因。50～70％的糖尿病病儿发生过1次或多次酮症酸中毒,约有1/3的儿童糖尿病患者以酮症酸中毒为首发症状。我科近15年来共收治糖尿病患儿20例,占同期住院人数之1.3‰,其中17例(85％)有酮尿,8例(40％)有酸中毒,4例     

儿童1型糖尿病的10年回顾及白介素-10在糖尿病酮症酸中毒中的临床意义

目的：回顾浙江大学医学院附属儿童医院10年来住院儿童 1 型糖尿病的发病状况并探讨白介素-10（IL-10）在儿童 1 型糖尿病酮症酸中毒（DKA）中的临床意义。方法：对1999年1月至2009年2月在该院住院的263例334例次1型糖尿病患儿的临床资料进行回顾性分析;并对其中48例1型糖尿病患儿进行血脂、细胞因子等检查,根据有无酮症酸中毒分为 DKA组和非DKA组,24例正常健康儿童作为对照组,比较各组间血脂、细胞因子等参数的差异。结果：儿童1型糖尿病患儿中,女性多见（56.3%）,发病年龄以6~11.9岁多见。32.7% 的患儿以酮症酸中毒为就诊表现。DKA组血脂、血糖及糖化血红蛋白均高于非DKA组,二分类logistic 回归分析示上述指标水平的升高均为酮症酸中毒的危险因素。IL-10水平在DKA组明显升高,余细胞因子在DKA组和非DKA组无明显差异。糖尿病组各细胞因子水平明显高于正常对照组。结论：1型糖尿病患儿酮症酸中毒发生率较高,糖、脂代谢紊乱是酮症酸中毒的危险因素。IL-10可能为酮症酸中毒的敏感指标。［中国当代儿科杂志,2010,12（11）：849-854］     

儿童糖尿病酮症酸中毒的治疗

糖尿病酮症酸中毒是儿童常见危急重症,治疗延误或治疗不当会影响糖尿病患儿的预后。国内儿科内分泌遗传代谢学组发布的糖尿病酮症酸中毒处理方案极大地提高了国内儿科救治水平,美国糖尿病学会2006年发布了小儿糖尿病酮症酸中毒治疗方案,与国内方案比较更为细化,在胰岛素治疗开始时间、纠正酸中毒指征及补钾等方面均有所不同,且更强调脑水肿的发现与治疗,值得借鉴。     

甲基丙二酸血症1例病例报告

目的 探讨甲基丙二酸血症被误诊为糖尿病酮症酸中毒、病毒性脑炎的原因。方法 对我院收治的先后被误诊为糖尿病酮症酸中毒、病毒性脑炎的甲基丙二酸血症患儿的临床资料进行描述分析。入院先后误诊为糖尿病酮症酸中毒、病毒性脑炎,最后确诊甲基丙二酸血症。结果 本例患儿具有呼吸深大、浅昏迷、高血糖、酸中毒等临床特点,临床上极易误诊为糖尿病酮症酸中毒,而此患儿颅脑MRI表现又容易误诊为病毒性脑炎。根据串联质谱血酰基肉碱分析示丙酰肉碱、丙酰肉碱与乙酰肉碱比值增高;尿液有机酸分析示甲基丙二酸及甲基枸橼酸增高,确诊为甲基丙二酸血症。结论 MMA临床表现不具特异性,应加强MMA的早期识别能力,对可疑患儿及早行串联质谱血酰基肉碱、气相色谱-质谱尿有机酸检测,减少误诊发生。     

儿童糖尿病酮症酸中毒的治疗（讲座）

糖尿病酮症酸中毒(DKA)是导致糖尿病患儿住院及死亡的最常见原因。据统计初发糖尿病患儿中,约有20～40％因DKA住院。近年来糖尿病患者酮症酸中毒(KA)的发生率已有所下降,但病死率却并没有随着治疗及监护水平的提高而明显降低。因此治疗的主要目标在于识别糖尿病的早期症状,对糖尿病患儿进行密切监视,以达到预防DKA的发生。     

连续性血液透析滤过治疗糖尿病酮症酸中毒危重患儿2例北大核心CSCD

对2017年苏州大学附属儿童医院内分泌遗传代谢科和重症医学科收治的2例糖尿病酮症酸中毒危重患儿的临床表现、实验室检查及抢救治疗过程进行回顾性分析。例1,女,13岁5个月,诊断"1型糖尿病、酮症酸中毒、急性肾损伤(3期)";例2,女,2个月8 d,诊断"新生儿糖尿病、酮症酸中毒、高渗高血糖综合征",予常规补液、胰岛素降糖治疗效果不佳,行连续性血液透析滤过治疗后缓解;为明确病因,行基因检测,例2检出KCNJ11基因存在c.602G>A(p.R201H)杂合突变。提示对于儿童糖尿病酮症酸中毒危重患者,在常规补液、胰岛素降糖治疗效果不佳,合并其他器官功能损伤及顽固性酸中毒时,积极行连续性血液透析滤过治疗,可获得显著效果。     

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。     

腹痛型糖尿病酮症酸中毒6例

本组 6例糖尿病酮症酸中毒患儿均为首次发病 ,以急性腹痛为首发和主要症状 ,表现为持续性全腹痛 ,5例伴呕吐或腹泻 ,6例均被误诊。给予抗感染、对症及支持等治疗无效。经血生化及尿常规检查考虑为糖尿病酮症 ,其中血糖 18.7～2 6 .1ｍｍｏｌ/Ｌ、尿酮体 ( ～ ) ,5例低钾、低钠 ,并经腹透、Ｂ超及详细查体 ,除外急腹症确诊为糖尿病酮症酸中毒。立即改用盐水扩容 ,给予胰岛素规范治疗 ,均完全缓解出院 ,随诊复查各生化指标维持正常。腹痛型糖尿病酮症酸中毒6例$大连市儿童医院!116012@陈爱勇     

儿童1型糖尿病90例

目的探讨儿童1型糖尿病(IDDM)的发病情况、临床特点、远期并发症及酮症酸中毒(DKA)的治疗。方法回顾性分析1993～2003年我院90例IDDM患儿的发病情况,临床特点,远期并发症,并探讨DKA的治疗。结果10～16岁儿童发病率最高,感染是诱发DKA的常见原因,未长期坚持胰岛素治疗易导致IDDM远期并发症的发生。结论小剂量胰岛素持续静滴、纠正水电解质紊乱、调节酸碱平衡是抢救DKA的关键;坚持长期胰岛素治疗是防治远期并发症IDDM的关键。     

Moderne Behandlungskonzepte für Kinder und Jugendliche mit Diabetes mellitus Typ 1

Diabetes mellitus type 1 is one of the most common chronic diseases in childhood. Acute treatment of diabetic ketoacidosis (DKA) includes treatment of shock, slow and moderate rehydration, correction of electrolyte deficits and substitution of insulin. The most severe complication is brain edema. Associated risk factors are rehydration with large volumes and hypotonic solutions, rapid decrease in serum osmolarity as well as duration and severity of clinical signs of DKA. Insulin therapy in children and adolescents includes the conventional two or multi-injection therapy and also insulin pump treatment. Continuous care of diabetic children and adolescents requires multidisciplinary teams including pediatric diabetologists, diabetes educators and psychologists. Furthermore, collaboration with ophthalmologists, gynecologists and pediatricians is mandatory.     

Diabetic ketoacidosis in the pediatric ICU

Diabetic ketoacidosis (DKA) is a common, life-threatening complication of diabetes mellitus in children. Central nervous system changes seen in DKA include the altered sensorium seen commonly in DKA and loosely characterized as diabetic coma and the uncommon but worrisome progressively deepening coma caused by cerebral edema, which has both a high morbidity and mortality. This article discusses the assessment and treatment of DKA in the setting of the pediatric ICU.     

ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents.

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.     

ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.     

Ketoacidosis at onset of type 1 diabetes mellitus in children--frequency and clinical presentation

Abstract: Background: Since 1987, patients with newly diagnosed diabetes mellitus type 1 under 15 yr of age have been registered in Baden‐Wuerttemberg (BW), Germany. Aim: Our aim was to describe the frequency and the clinical presentation of diabetic ketoacidosis (DKA) at onset of type 1 diabetes mellitus in children. Methods: All 31 pediatric departments in BW and one diabetes center participated in this study. Hospital records of 2121 children below 15 yr of age were examined retrospectively. DKA was defined as glucose > 250 mg/dL, pH < 7.30 or bicarbonate < 15 mmol/L and ketonuria. Statistical analysis was done after logarithmic transformation. Results: 26.3% (n = 558) of all patients presented with DKA. The mean age of these patients was 7.9 yr. The frequency of DKA is higher in girls than in boys (28.9 vs. 23.8%; p = 0.0079). Those aged 0–4 yr suffered most frequently (p < 0.0001) from ketoacidosis (36.0%). The percentage of DKA in newly diagnosed cases was constant over 10 yr. 23.3% of all patients with DKA presented with an altered level of consciousness; 10.9% of these had clinical signs of coma. No deaths occurred. The proportion of ketoacidosis does not increase concurrently with the number of diabetes manifestations in winter. Conclusion: The proportion of DKA in children with newly diagnosed diabetes mellitus is significant. In particular, children < 5 yr and girls face an increased risk. DKA may be the result of a particularly aggressive subtype of diabetes.     

Prävalenz von Ketoazidosen bei Manifestation des Diabetes mellitus Typ 1 in einem Zentrum für pädiatrische Diabetologie

Introduction. Diabetic ketoacidosis (DKA) is still the most serious complication of the newly diagnosed child with diabetes mellitus type 1 because it is still the most common cause of death due to cerebral edema. Methods. All patient records of children with new diagnosed type 1 diabetes mellitus in the children's hospital of the University of Leipzig in 1995 to 1999 were analysed retrospectively. Results. 31 patients (29,8%) had DKA, 10 of which were unconscious or somnolent. In those children and adolescents with DKA blood glucose levels, glycosylated hemoglobin levels and initial insulin requirement were higher and the duration of hospital stay was longer. The rate of remission was lower in the DKA group (67 vs. 80.8%). A delayed or false diagnosis was reported in 14% of patients without but in 22,5% of the children and adolescents with DKA. Conclusion. To improve the rate of remission and reduce the hospital stay at the onset of diabetes mellitus the rate of DKA must be reduced due to better information about symptoms of diabetes mellitus in the general population and especially among general practitioners and pediatricians.     

Management of Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus (DM), occurs more commonly in children with type 1 DM than type 2 DM. Hyperglycemia, metabolic acidosis, ketonemia, dehydration and various electrolyte abnormalities result from a relative or absolute deficiency of insulin with or without an excess of counter-regulatory hormones. Management requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema. Cerebral edema may be life threatening and is managed with fluid restriction, administration of mannitol and ventilatory support as required. Factors precipitating the episode of DKA should be identified and rectified. Following resolution of ketoacidosis, intravenous insulin is transitioned to subcutaneous route, titrating dose to achieve normoglycemia.     

Profound hypokalemia associated with severe diabetic ketoacidosis

Hypokalemia is common during the treatment of diabetic ketoacidosis (DKA); however, severe hypokalemia at presentation prior to insulin treatment is exceedingly uncommon. A previously healthy 8‐yr‐old female presented with new onset type 1 diabetes mellitus, severe DKA (pH = 6.98), and profound hypokalemia (serum K = 1.3 mmol/L) accompanied by cardiac dysrhythmia. Insulin therapy was delayed for 9 h to allow replenishment of potassium to safe serum levels. Meticulous intensive care management resulted in complete recovery. This case highlights the importance of measuring serum potassium levels prior to initiating insulin therapy in DKA, judicious fluid and electrolyte management, as well as delaying and/or reducing insulin infusion rates in the setting of severe hypokalemia.     

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。