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Preventing Cerebral Edema In Dka

A Rare And Lethal Complication: Cerebral Edema In The Adult Patient With Diabetic Ketoacidosis

A Rare And Lethal Complication: Cerebral Edema In The Adult Patient With Diabetic Ketoacidosis

A Rare and Lethal Complication: Cerebral Edema in the Adult Patient with Diabetic Ketoacidosis Correspondence should be addressed to Christopher W. Meaden ; [email protected] Received 20 July 2017; Revised 9 January 2018; Accepted 18 February 2018; Published 21 March 2018 Copyright 2018 Christopher W. Meaden et al. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Commonly seen in the emergency department, diabetic ketoacidosis is a potentially lethal sequela of uncontrolled diabetes mellitus. In the adult population, a rare complication of diabetic ketoacidosis is cerebral edema. This case report discusses a 26-year-old male with new onset diabetes mellitus who developed cerebral edema leading to death. An unfortunate, yet common, complication of uncontrolled diabetes is diabetic ketoacidosis (DKA). A combination of elevated blood glucose in the setting of depleted insulin availability creates an acidic environment from the production of -hydroxybutyric acid and acetoacetic acid [ 1 ]. DKA has been linked to several devastating metabolic derangements including osmotic diuresis, depletion of intracellular potassium, accumulation of toxic ketoacids, and dysregulation of sodium hydrogen exchanger mechanisms [ 2 , 3 ]. A destructive consequence secondary to these abnormalities is cerebral edema (CE) that has been documented throughout the pediatric literature, but more sporadically in the adult literature. Cerebral edema results in poor outcomes with mortality occurring in 2125% of patients and neurological morbidity occurring in 1526% of patients [ 4 ]. A 26-year-old African American male, with Continue reading >>

Management Of Diabetic Ketoacidosis

Management Of Diabetic Ketoacidosis

Diabetic ketoacidosis is an emergency medical condition that can be life-threatening if not treated properly. The incidence of this condition may be increasing, and a 1 to 2 percent mortality rate has stubbornly persisted since the 1970s. Diabetic ketoacidosis occurs most often in patients with type 1 diabetes (formerly called insulin-dependent diabetes mellitus); however, its occurrence in patients with type 2 diabetes (formerly called non–insulin-dependent diabetes mellitus), particularly obese black patients, is not as rare as was once thought. The management of patients with diabetic ketoacidosis includes obtaining a thorough but rapid history and performing a physical examination in an attempt to identify possible precipitating factors. The major treatment of this condition is initial rehydration (using isotonic saline) with subsequent potassium replacement and low-dose insulin therapy. The use of bicarbonate is not recommended in most patients. Cerebral edema, one of the most dire complications of diabetic ketoacidosis, occurs more commonly in children and adolescents than in adults. Continuous follow-up of patients using treatment algorithms and flow sheets can help to minimize adverse outcomes. Preventive measures include patient education and instructions for the patient to contact the physician early during an illness. Diabetic ketoacidosis is a triad of hyperglycemia, ketonemia and acidemia, each of which may be caused by other conditions (Figure 1).1 Although diabetic ketoacidosis most often occurs in patients with type 1 diabetes (formerly called insulin-dependent diabetes mellitus), more recent studies suggest that it can sometimes be the presenting condition in obese black patients with newly diagnosed type 2 diabetes (formerly called non–insulin-depe Continue reading >>

Emdocs.net Emergency Medicine Educationa Well-grounded Myth? The Association Of Iv Fluids With Cerebral Edema In Pediatric Dka - Emdocs.net - Emergency Medicine Education

Emdocs.net Emergency Medicine Educationa Well-grounded Myth? The Association Of Iv Fluids With Cerebral Edema In Pediatric Dka - Emdocs.net - Emergency Medicine Education

A Well-Grounded Myth? The Association of IV Fluids with Cerebral Edema in Pediatric DKA Author: Brit Long, MD (@long_brit, EM Attending Physician at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) A 5-year-old little girl presents with vomiting, polyuria, and polydipsia. She has a history of type 1 diabetes on insulin. Her mom called her endocrinologist, who recommended they come in to the ED. Her vital signs demonstrate tachycardia and hypotension, and she appears ill. You order a VBG, urinalysis, CBC, renal function, and lactate, and while you consider your rehydration strategy, the endocrinologist calls and asks you to do maintenance therapy only. The patient looks ill, with hemodynamic abnormalities. Whats the literature behind cerebral edema (CE) and fluid rehydration in pediatric DKA? This post will evaluate this topic and more. Type 1 and 2 diabetes mellitus is a common chronic disease among children.1-5 A major complication is DKA with a 25% incidence.3-8 Almost 1/3 of patients have DKA at the time of initial diabetes diagnosis.3-7 Younger age, smaller body mass index, delayed treatment, infectious trigger, and lack of health insurance are risk factors for DKA.1,2,8 Even type 2 diabetics may experience DKA, with 5-25% of patients in DKA at time of diagnosis of type 2 diabetes.4,8,9 Insulin omission and infection are the most common sources for DKA.1,2 Pediatric DKA consists of hyperglycemia (serum glucose greater than 200 mg/dL), anion gap metabolic acidosis, and ketonemia.1,10-14 DKA is due to absolute or relative deficiency in insulin and excess counterregulatory hormones, with dehydration and electrolyte abnormalities. Rehydration with fluids, insulin, and potentia Continue reading >>

Increased Activity Of Inflammasomes As Osmosensors As Cause Of Cerebral Edema In Diabetic Ketoacidosis

Increased Activity Of Inflammasomes As Osmosensors As Cause Of Cerebral Edema In Diabetic Ketoacidosis

Increased activity of inflammasomes as osmosensors as cause of cerebral edema in diabetic ketoacidosis Diabetic ketoacidosis (DKA) related cerebral edema (CE) is associated with a high mortality and rate of neurodisability and neurocognitive difficulties. In 54% of children with DKA there is subclinical evidence of CE on MRI studies. It is known that DKA is accompanied by a systemic inflammatory response characterized by elevated cytokine levels including interleukin-1 (IL-1) and interleukin-6. IL-1 has been linked to the pathogenesis of CE. Inflammasomes like nucleotide binding domain and leucine-rich repeat containing proteins 3 (NRLP3) are multiprotein complexes generating the active form of IL-1 in response to high glucose levels. The resulting hypothesis is that increased activity of inflammasomes as osmosensors is the cause of CE in diabetic ketoacidosis. Confirmation of the hypothesis could be achieved by correlation of IL-1 and NRLP3 levels and expression with degree of subclinical CE on MRI imaging and peripheral blood glial fibrillary acidic protein levels (a marker of brain injury). If confirmed future randomized controlled trials could use NRLP3 inhibitors and IL-1 antagonists as auxiliary treatment in DKA and measure neurocognitive outcome. NLRP, cerebral edema, systemic inflammatory response syndrome Clinically manifest cerebral edema (CE) in diabetic ketoacidosis is rare in high income countries (0 to 5.5% of cases) and significantly more common in low income countries (24 to 26% of cases) [1]. Mortality of severe diabetic ketoacidosis (DKA) is high with more than 20% and survivors are at a significant risk of at least 27% [2] of permanent neurodisability. The pathogenesis of the associated CE is unclear. There is subclinical and mild, not formally diagn Continue reading >>

Risk Factors For Cerebral Oedema In Children And Adolescents With Diabetic Ketoacidosis

Risk Factors For Cerebral Oedema In Children And Adolescents With Diabetic Ketoacidosis

Risk factors for cerebral oedema in children and adolescents with diabetic ketoacidosis ?Mathematical formulae have been encoded as MathML and are displayed in this HTML version using MathJax in order to improve their display. Uncheck the box to turn MathJax off. This feature requires Javascript. Click on a formula to zoom. Cerebral oedema (CO) is a rare life-threatening complication of diabetic ketoacidosis (DKA) in children. We analysed the biochemical and therapeutic risk factors for CO in DKA by a retrospective review of 256 children hospitalized for DKA between February 2003 and March 2015. The demographic characteristics, biochemical variables and therapeutic interventions were compared between the patients with and without CO. CO was observed in 22 (8.6%) of the 256 subjects included in the study. One of these patients (5%) had a fatal outcome and two patients (9%) survived with neurological consequences. CO was significantly associated with severe DKA: lower initial venous pH (p < 0.001) and bicarbonate (p < 0.001), higher initial blood glucose (p < 0.01), urea level (p < 0.05) and baseline serum osmolality ( < 0.05). During the treatment of DKA, low serum phosphate level was found to be significantly associated with CO (p < 0.05). We also found significant dependence between the development of CO and the initiation of treatment for DKA in another facility before hospitalization in our hospital (p < 0.05), bicarbonate application (p < 0.001), higher fluid volume infused initially (p < 0.01) and delayed potassium substitution (p < 0.01). Severe ketoacidosis, hyperglycaemia and dehydration at presentation, and low serum phosphate during treatment are significantly related to CO formation in children with DKA. The initial severe acidosis and hyperglycaemia probabl Continue reading >>

Unusual Case Of New Onset Diabetes Mellitus Presenting With Diabetic Ketoacidosis And Cerebral Edema With Literature Review

Unusual Case Of New Onset Diabetes Mellitus Presenting With Diabetic Ketoacidosis And Cerebral Edema With Literature Review

Nitasa Sahu*, Emma Punni, Chandra Chandran and Medhat Ismail Department of Internal Medicine, St. Joseph’s Regional Medical Center, New York Medical College, Paterson, USA Citation: Sahu N, Punni E, Chandran C, Ismail M (2016) Unusual Case of New Onset Diabetes Mellitus Presenting with Diabetic Ketoacidosis and Cerebral Edema with Literature Review. J Nephrol Ther 6: 262. doi:10.4172/2161-0959.1000262 Copyright: © 2016 Sahu N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License; which permits unrestricted use; distribution; and reproduction in any medium; provided the original author and source are credited. Visit for more related articles at Journal of Nephrology & Therapeutics Abstract Diabetic ketoacidosis (DKA) is typically treated with volume replacement (most commonly normal saline), insulin and monitored via serial chemistry and glucose lab values. Cerebral edema, a complication occurring in approximately 1% of DKA presentations in children, with a mortality of 40-90%, has no clear identifiable risk factors. While many cases have been reported in children, there are only a few cases of clinically significant cerebral edema in adults. It is postulated the underlying mechanism is similar to that in children; excessive fluid resuscitation, rapid reduction in plasma osmolarity, and/or the administration of sodium bicarbonate. We are reporting a case of a 26 year old male with no prior medical history, who presented in diabetic ketoacidosis and was treated as per the American Diabetic Association guidelines, however, deteriorated rapidly after acute complaints of headache and irritability consistent with diffuse cerebral edema. Keywords Diabetic ketoacidosis; Cerebral edema; Adult; Mortality Introduction Dia Continue reading >>

Preventing A Drop In Effective Plasma Osmolality To Minimize The Likelihood Of Cerebral Edema During Treatment Of Children With Diabetic Ketoacidosis - Sciencedirect

Preventing A Drop In Effective Plasma Osmolality To Minimize The Likelihood Of Cerebral Edema During Treatment Of Children With Diabetic Ketoacidosis - Sciencedirect

Volume 150, Issue 5 , May 2007, Pages 467-473 Preventing a Drop in Effective Plasma Osmolality to Minimize the Likelihood of Cerebral Edema During Treatment of Children with Diabetic Ketoacidosis Author links open overlay panel Ewout J.HoornMD Get rights and content To test whether a drop in effective plasma osmolality (PEff osm; 2 plasma sodium [PNa] + plasma glucose concentrations) during therapy for diabetic ketoacidosis (DKA) is associated with an increased risk of cerebral edema (CE), and whether the development of hypernatremia to prevent a drop in the PEff osm is dangerous. This study is a retrospective comparison of a CE group (n = 12) and non-CE groups with hypernatremia (n = 44) and without hypernatremia (n = 13). The development of CE (at 6.8 1.5 hours) was associated with a drop in PEff osm from 304 5 to 290 5 mOsm/kg (P < .001). Control patients did not show this drop in PEff osm at 4 hours (1 2 and 2 2 vs 9 2 mOsm/kg; P < .01), because of a larger rise in PNa and/or a smaller drop in plasma glucose. During this period, the CE group received more near-isotonic fluids (69 9 vs 35 2 and 27 3 mL/kg; P < .001). The CE group had a higher mortality (3/12 vs 0/57; P = .003), and more neurologic sequelae (5/12 vs 1/57; P < .001). CE during therapy for DKA was associated with a drop in PEff osm. An adequate rise in PNa may be needed to prevent this drop in PEff osm. Continue reading >>

How Can Cerebral Edema During Treatment Of Diabetic Ketoacidosis Be Avoided?

How Can Cerebral Edema During Treatment Of Diabetic Ketoacidosis Be Avoided?

How can cerebral edema during treatment of diabetic ketoacidosis be avoided? Corresponding author: Julie Edge, MD, FRCPCH,Oxford Children's Hospital,Oxford OX3 9DU,UK.Tel: +44 1865 231673;fax: +44 1865 234211;email: [email protected] Please review our Terms and Conditions of Use and check box below to share full-text version of article. I have read and accept the Wiley Online Library Terms and Conditions of Use. Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Get access to the full version of this article.View access options below. You previously purchased this article through ReadCube. View access options below. Logged in as READCUBE_USER. Log out of ReadCube . Cerebral edema during diabetic ketoacidosis (DKA) is a rare complication but it can be devastating, with significant mortality and longterm morbidity. Certain risk factors have been teased out with some large casecontrol studies, but more research needs to be done to make management guidelines safer. This article will discuss how DKA might be prevented from occurring in the first instance, known risk factors for cerebral edema, fluid and insulin management, the importance of careful monitoring during DKA treatment, and the importance of recognizing and acting on the earliest symptoms to prevent longterm harm. Continue reading >>

Cerebral Edema And Diabetic Ketoacidosis

Cerebral Edema And Diabetic Ketoacidosis

Cerebral edema is the most feared emergent complication of pediatric diabetic ketoacidosis. Fortunately, it is relatively rare, but the rarity can lead to some confusion when it comes to its management. We recently discussed the use of mannitol and hypertonic saline for pediatric traumatic brain injury , but when should we consider these medications for the patient presenting with DKA? Overall tends to occur in the newly diagnosed diabetic patient (4.3% vs 1.2%). While rare, it is a devastating complication. 1990 study showed case fatality rate was 64%. Those treated BEFORE respiratory failure had lower rate of mortality (30%). The exact mechanism is not known and may be varied between individual patients. 66% within the first 7 hours of treatment (these tend to be younger). ~40% of initial brain imaging of kids with cerebral edema are NORMAL! Risk Factors for Developing Cerebral Edema This is the area that often leads to finger pointing most often those fingers being pointed toward the Emergency Physician who was initially caring for the kid. Much of the literature focused on interventions, but: Sodium Bicarb was shown to be associated with Cerebral Edema in one study Unfortunately, this study did not adjust for illness severity. Generally, there is an absence of evidence that associates volume, tonicity, or rate change in serum glucose with Cerebral Edema development. There are cases presenting with cerebral edema prior to any therapies. Risk Factors that seem to stay consistent: Early detection and treatment is the best means to prevent brain injury and death. But, abnormal neurological signs are common in kids with DKA and they dont all need therapy. Muir et al published a Bedside Evaluation of Neuro State of Kids with DKA Abnormal motor or verbal response to pain Continue reading >>

How Can Cerebral Edema During Treatment Of Diabetic Ketoacidosis Be Avoided?

How Can Cerebral Edema During Treatment Of Diabetic Ketoacidosis Be Avoided?

Abstract Cerebral edema during diabetic ketoacidosis (DKA) is a rare complication but it can be devastating, with significant mortality and long-term morbidity. Certain risk factors have been teased out with some large case-control studies, but more research needs to be done to make management guidelines safer. This article will discuss how DKA might be prevented from occurring in the first instance, known risk factors for cerebral edema, fluid and insulin management, the importance of careful monitoring during DKA treatment, and the importance of recognizing and acting on the earliest symptoms to prevent long-term harm. Continue reading >>

Cerebral Edema: A Complication Of Dka

Cerebral Edema: A Complication Of Dka

DKA, or diabetic ketoacidosis, is a severe life-threatening medical complication that must be treated by doctors in a hospital. DKA is a condition in which blood glucose levels have risen dangerously high due to lack of insulin and insulin resistance. Fat begins to break down in response to energy requirements leading to high ketone levels in the blood causing your blood to become too acidic. DKA sometimes leads to cerebral edema, which is brain swelling, and if left untreated, cerebral edema can cause brain damage or lead to death. Cerebral Edema: Its relationship to DKA In order to understand cerebral edema, you must understand diabetic ketoacidosis (DKA). DKA is a situation in which blood sugar levels rise to dangerous levels in response to a lack of insulin and insulin resistance. The liver keeps producing glucose, which collects in the blood. Normally, insulin will move that glucose out of the blood and into the cells that need it, but when there is insufficient insulin or significant insulin resistance, the glucose builds up to dangerous levels (severe hyperglycemia). Because the cells that need the glucose are not getting it (remember the glucose is stuck in the blood), they signal the body to produce more glucose through the breakdown of fat. The breakdown of fat results in fat components called ketones. When ketones continue to build up in your blood stream, the patient develops a condition called diabetic ketoacidosis or DKA. Symptoms include: Abdominal pain Signifant thirst Blurry vision Nausea and vomiting[1] Polyuria (Frequent urination) Polydipsia – excessive thirst that lasts for a day or more Weight loss Weakness Confusion Cold body temperature Acetone on the breath, Rapid breathing that is shallow then deep and labored– called Kussmaul’s respirati Continue reading >>

Appropriate Therapy Can Prevent Cerebral Swelling In Diabetic Ketoacidosis

Appropriate Therapy Can Prevent Cerebral Swelling In Diabetic Ketoacidosis

Appropriate therapy can prevent cerebral swelling in diabetic ketoacidosis (DKA) In considering the issue posed by the title, there are two aspects of fluid movement in the brain that should be emphasized before we consider the pathophysiology of DKA and its treatment. The first is a generalized response to induced hyperosmolality in the extracellular space (ECF). What are now known as osmolytes, previously called idiogenic osmols, small organic molecules that accumulate in cells. In mammals taurine and myoinositol are the principal (only?) osmolytes. These molecules diffuse out or metabolize very slowly when a return to normal osmolality has occurred. Because the brain is in a rigid box, such cell swelling will lead to increased intracranial pressure when there is continuing hyperosmolality without loss of ECF volume. The second aspect of fluid movement in and out of the brain relevant here is the nature of the capillaries through which water and solute diffuse. The brain capillaries, unlike most capillaries elsewhere in the body, have tight junctions between the cells. This anatomic feature produces the blood brain barrier. Solutes not actively transported across the membrane, which includes sodium and chloride ions, diffuse at a much slower rate than these ions diffuse across other capillaries where movement is nearly instantaneous. In the brain, equilibrium for sodium takes 6 h ( 1 ). On the other hand, diffusion of water is virtually instantaneous in the brain as elsewhere. Consider, then, what happens when an osmotic gradient between the plasma and brain fluid is created. Water moves instantly to equalize the osmotic concentrations while the dominant solutes (Na+ and Cl) move slowly. If the dilution gradient is from plasma to brain ECF, there will be an increase Continue reading >>

Diabetic Ketoacidosis/cerebral Edema

Diabetic Ketoacidosis/cerebral Edema

How can diabetic ketoacidosisrelated cerebral edema be prevented? OVERVIEW: What every practitioner needs to know Are you sure your patient has diabetic ketoacidosisrelated cerebral edema? What are the typical findings for this disease? Cerebral edema is a potentially life-threatening complication of diabetic ketoacidosis (DKA) and is responsible for the majority of diabetes-related deaths in children. Cerebral edema typically occurs after several hours of treatment with insulin and intravenous fluids but can also occur at the time of presentation of DKA before treatment is started. The risk of cerebral edema is related to the severity of acidosis, hypocapnia, and dehydration at the time of presentation of DKA. Although severe, clinically apparent cerebral edema occurs in just 1% of DKA episodes in children, numerous studies have demonstrated that mild cerebral edema, associated with only minimal or no alterations in mental status, is present in the majority of children during DKA treatment. The relationship between intravenous fluid treatment and the risk of DKA-related cerebral edema is frequently debated; however, there are no clear associations between the use of particular fluid treatment protocols and increased risk of DKA-related cerebral edema. At present, whether and how cerebral edema can be prevented is unknown. Treatment for clinically apparent cerebral edema typically involves use of hyperosmolar agents (mannitol or hypertonic saline). DKA-related cerebral edema is a clinical diagnosis. Imaging studies may be helpful but are not always definitive. The most common symptoms of DKA-related cerebral edema include mental status changes (confusion, irritability, obtundation) associated with severe headache, recurrence of vomiting, seizures, hypertension, inappro Continue reading >>

What Are The Diagnostic Criteria For Cerebral Edema In Diabetic Ketoacidosis (dka)?

What Are The Diagnostic Criteria For Cerebral Edema In Diabetic Ketoacidosis (dka)?

What are the diagnostic criteria for cerebral edema in diabetic ketoacidosis (DKA)? Muir et al have identified diagnostic criteria for cerebral edema that include abnormal response to pain, decorticate and decerebrate posturing, cranial nerve palsies, abnormal central nervous system respiratory patterns, fluctuating level of consciousness, sustained heart rate deceleration, incontinence, and more nonspecific criteria such as vomiting, headache, lethargy, and elevated diastolic blood pressure. [ 27 ] Cerebral edema begins with mental status changes and is believed to be due partially to idiogenic osmoles, which have stabilized brain cells from shrinking while the diabetic ketoacidosis was developing. Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [Medline] . Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009 Jul. 32(7):1164-9. [Medline] . [Full Text] . Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. 2012 Jan. 29(1):32-5. [Medline] . Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. 2009 Jun 26. [Medline] . Bowden SA, Duck MM, Hoffman RP. Young children (12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabet Continue reading >>

Krane: Dka And Cerebral Edema

Krane: Dka And Cerebral Edema

In 1922 Banting and Best introduced insulin into clinical practice.A decade later the first reported case of cerebral edema complicatingdiabetic ketoacidosis (DKA) was reported by Dillon, Riggs andDyer writing in the pathology literature. While the syndrome ofcerebral edema complicating DKA was either not seen, ignored,or was unrecognized by the medical community until 3 decades laterwhen the complication was again reported by Young and Bradleyat the Joslin Clinic, there has since been a flurry of case reportsin the 1960's and 1970's and basic and clinical research fromthe 1970's to the 1990's leading to our present day acceptanceof this as a known complication of DKA, or of the management ofDKA. In fact, we now recognize that the cerebral complications of DKA(including much less frequent cerebral arterial infarctions, venoussinus thrombosis, and central nervous system infections) are themost common cause of diabetic-related death of young diabeticpatients ( 1 ), accounting for 31% of deathsassociated with DKA and 20% of all diabetic deaths, having surpassedaspiration, electrolyte imbalance, myocardial infarction, etc. Furthermore, diabetes mellitus remains an important cause of hospitalizationof young children. The prevalence rate of diabetes continues togrow in all Western developed nations, nearly doubling every decade,resulting in 22,000 hospital admissions in children under 15 yearsof age for diabetes in the United States in 1994, the majorityof which were due to ketoacidosis. With approximately 4 hospitaladmissions of children for DKA per 100,000 population per year( 2 ), every PICU located in a major metropolitancenter will continue to see children with DKA at significant ratesin the future, and every pediatric intensivist will see at leastone case of cerebral e Continue reading >>

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