title: Transcranial Doppler-based assessment of cerebral autoregulation in critically ill children during diabetic ketoacidosis treatment.
abstract: OBJECTIVE
  Impaired cerebral autoregulation may be associated with poor outcome in diabetic ketoacidosis. We examined change in cerebral autoregulation during diabetic ketoacidosis treatment.
  
  
  METHODS
  Prospective observational cohort study.
  
  
  METHODS
  Tertiary care children's hospital.
  
  
  METHODS
  Children admitted to the ICU with diabetic ketoacidosis (venous pH < 7.3, glucose > 300 mg/dL, HCO3 < 15 mEq/L, and ketonuria) constituted cases, and children with type I diabetes without diabetic ketoacidosis constituted controls.
  
  
  METHODS
  None.
  
  
  RESULTS
  Between 2005 and 2009, 32 cases and 50 controls were enrolled. Transcranial Doppler ultrasonography was used to measure middle cerebral artery flow velocities, and cerebral autoregulation testing was achieved via tilt-table testing. Cases underwent two and controls underwent one cerebral autoregulation test. Cerebral autoregulation was quantified by the autoregulatory index (autoregulatory index < 0.4 = impaired and autoregulatory index 0.4-1.0 = intact autoregulation). The first autoregulation test was obtained early (time 1, 12-24 hr; median [interquartile range], 8 hr [5-18 hr]) during diabetic ketoacidosis treatment, and a second autoregulation test was obtained during recovery (time 2, 36-72 hr; median [ interquartile range], 46 hr [40-59 hr]) from time 0 (defined as time of insulin start). Cases had lower autoregulatory index at time 1 than time 2 (p < 0.001) as well lower autoregulatory index than control subjects (p < 0.001). Cerebral autoregulation was impaired in 40% (n = 13) of cases at time 1 and in 6% (n = 2) of cases at time 2. Five cases (17%) showed persistent impairment of cerebral autoregulation between times 1 and 2 of treatment. All control subjects had intact cerebral autoregulation.
  
  
  CONCLUSIONS
  Impaired cerebral autoregulation was common early during diabetic ketoacidosis treatment. Although the majority improved during diabetic ketoacidosis treatment, 17% of subjects had impairment between 36 and 72 hours after start of insulin therapy. The observed impaired cerebral autoregulation appears specific to the diabetic ketoacidosis process in patients with type I diabetes.
authors: 1Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA. 2Department of Pediatrics, University of Washington, Seattle, WA. 3Seattle Children's Hospital, Seattle, WA. 4Department of Radiology, University of Washington, Seattle, WA.
authors: Li
authors: L
authors: Ma
authors: Joan S
authors: JS
authors: Roberts
authors: Catherine
authors: C
authors: Pihoker
authors: Todd L
authors: TL
authors: Richards
authors: Dennis W W
authors: DW
authors: Shaw
authors: Ken I
authors: KI
authors: Marro
authors: Monica S
authors: MS
authors: Vavilala
mesh_terms: D000293:Adolescent; D001783:Blood Flow Velocity; D001929:Brain Edema / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D054022:Cerebrum / Q000098:blood supply / Q000000981:diagnostic imaging / Q000503:physiopathology*; D002648:Child; D016638:Critical Illness; D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D016883:Diabetic Ketoacidosis / Q000188:drug therapy / Q000209:etiology / Q000503:physiopathology*; D005260:Female; D006706:Homeostasis; D006801:Humans; D006973:Hypertension / Q000209:etiology; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D020768:Middle Cerebral Artery / Q000503:physiopathology*; D011446:Prospective Studies; D018667:Tilt-Table Test; D017585:Ultrasonography, Doppler, Transcranial
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin