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Brain blood flow in diabetic ketoacidosis
Anyone who has treated children with diabetic ketoacidosis (DKA) will know how frightening the prospect of sudden, unexpected cerebral oedema can be. The phenomenon is thought to be an idiosyncratic cerebral hyperaemia response to fluid treatment. Researchers in Sacramento, California used a new technique, near infrared spectroscopy (NIRS), to study 19 episodes of DKA in children aged 8–18 years (Glaser N et al. J Pediatr 2013;163:1111–16). The technique involves applying a probe to the left side of the patient's forehead, allowing continuous monitoring of regional cerebral oxygen saturation (rSo2) in the anterior brain. Patients were randomised to one of two treatment arms using 0.9% saline: rapid rehydration (two boluses of 10 mL/kg followed by replacement of 2/3 assumed 10% deficit over 24 h), or slower rehydration (one bolus and replacement of assumed 7% deficit over 48 h). Insulin treatment was the same for both. They found no difference in rSo2 levels between the groups, suggesting that slower rehydration might not prevent cerebral oedema. Only one patient (in the rapid arm) developed any cerebral symptoms: a drop in conscious level that responded rapidly to mannitol. However, more interesting was the observation that in 17/19 cases, rSo2 levels were significantly high from as early as 2 h from …