Dehydration in Children with Diabetic Ketoacidosis: a Prospective Study: Sottosanti M, Morrison GC,...

750 Abstracts

coronary artery calcification score (CACS). Patients were strat-ified by eGFR as having normal renal function, mild renal dys-function, or moderate renal dysfunction. Using logisticregression and adjusting for traditional risk factors, the authorsfound a correlation coefficient of �0.156 between eGFR andCACS, which was statistically significant (p < 0.001). Theauthors concluded that eGFR is an independent predictor ofincreased coronary artery calcification.

[Nir Harish, MD

Denver Health Medical Center, Denver, CO]

Comments: This study adds to the growing body of literaturedemonstrating that even mild renal dysfunction portends worsecardiovascular disease outcomes. This correlation is relevant toEmergency Physicians, who must routinely estimate the risk ofshort-term cardiovascular morbidity in patients with clinicallysuspected but unproven coronary artery disease. However, theutility of this study is limited by the use of the CACS, whichis not readily applicable to clinical practice. Further researchwill be needed to determine whether eGFR can be used to pre-dict clinically relevant outcomes.

, DEHYDRATION IN CHILDREN WITH DIABETICKETOACIDOSIS: A PROSPECTIVE STUDY. Sottosanti M,Morrison GC, Singh RN, et al. Arch Dis Child 2012;97:96–100.

This prospective descriptive study set in a tertiary care child-ren’s hospital investigated the association between the magni-tude of dehydration, defined as percent loss of body weight(LBW), determined by the difference in body weight obtainedat presentation and at discharge and the relationship betweenthe magnitude of dehydration and clinical assessment and bio-chemical parameters obtained on admission of 39 consecutivepediatric patients (age range 1 month–16 years) presentingwith 42 episodes of diabetic ketoacidosis (DKA). All patientswere treated according to a previously established protocolthat is a more restrictive (about 25% less) regimen than recom-mended in the literature. The median (25th–75th percentiles)magnitude of dehydration, based on LBW, was 5.7% (3.7–8.3%) (range 1.4–24.8%) or 8.9% (6.0–13.5%) (range 1.9–41.0%) when corrected for percent of total body water. Neitherthe initial clinical assessment nor the comprehensive biochem-ical profile at admission correlated with the magnitude of dehy-dration. Sodium and corrected sodium level were the onlybiochemical variables to show a reasonable correlation withthe severity of dehydration (r = 0.35, p = 0.02 and r = 0.502,p = 0.001, respectively). The speed of patient recovery did notcorrelate with the magnitude of dehydration on presentationnor the amount of fluid administered (median [25th–75th per-centiles] 48.8 mL/kg [38.5–60.3]) in the first 12 h and all pa-tients recovered from DKA within 24 h, with no patientshaving experienced permanent neurological impairment. Theauthors recommend that because the magnitude of dehydrationcannot be assessed accurately by either clinical or biochemicalparameters, a relatively restrictive regimen of fluid administra-tion should be employed for the timely correction of DKAunless the patient is hemodynamically unstable.

[Douglas Melzer, MD

Denver Health Medical Center, Denver, CO]

Comments:Under-administration and over-administration offluid may increase patient morbidity by delaying the correctionofDKAor by increasing the risk of cerebral edema, respectively;and recent guidelines recommend assuming 7–10% dehydrationin all patients presenting in DKA unless the patient is hemody-namically unstable. This very small study argues that the magni-tude of dehydration has little effect on the rapidity of recovery inpediatric DKA, but further research is needed to clarify the issue.

, CLOSED TREATMENT OF OVERRIDING DISTALRADIAL FRACTURE WITHOUT REDUCTION INCHILDREN. Crawford SN, Lee LS, Izuka BH. J Bone JointSurg Am 2012;94:246–52.

This was a retrospective case series of 51 consecutive pa-tients seen between 2004 and 2009 evaluating a treatment pro-tocol for pediatric distal radius fractures in which a short-armfiberglass cast was applied without an attempt at anatomic frac-ture reduction and the fracture was left shortened in an overrid-ing position. Inclusion criteria were age# 10 years and a closedoverriding fracture of the distal radial metaphysis with or with-out an associated fracture of the ulna. Exclusion criteria wereopen fractures, physeal involvement, metabolic bone disease,neurovascular injury, or the presence of another skeletal injury.An overriding position was defined as 100% dorsal translationand shortening of the distal radial segment. Follow-up was car-ried out at 1 week, 2 weeks, 6 weeks, and 1 year. A short-armfiberglass cast was gently molded to correct angulation (whichwas not always fully corrected) but with no attempt to correctshortening. The majority of patients had one cast change aftersoft-tissue swelling subsided; some returned for a second castchange at the senior author’s discretion. Average age was 6.9years, the left extremity was involved in 24 patients, and 6 pa-tients had an isolated radial fracture. The average time spentin a cast was 42 days (range 30–89 days). Seven patients hadfailed at least one attempt at closed reduction before study treat-ment. Initial radial shortening was 5 6 2.5 mm (range 1–14 mm). At cast removal, only a few patients had a minimallynoticeable clinical deformity; therefore, no objective measure-ments of radial shortening deformity were made. Initial angula-tion averaged 4.0 6 4.1� (range 0–13�) and 3.2 6 3.1� (range0–10�) in sagittal and coronal planes, respectively. At final fol-low-up, angulation had corrected to 2.2 6 2.7� (range 0–10�)and 0.75 6 1.4� (range 0–5�) in sagittal and coronal planes, re-spectively. There were no instances of malunion, non-union,cross-union, refracture, physeal injury, or neurovascular injury.Parents and guardians of all children were satisfied with treat-ment based on a two-question questionnaire. Financial analysisusing Current Procedural Terminology codes and average totalcost of care demonstrated that closed reduction under conscioussedation or general anesthesia would have been nearly five to sixtimes more expensive, and percutaneous pin fixation nine-foldmore expensive than the treatment used in the study.

[Omeed Saghafi, MD

Denver Health Medical Center, Denver, CO]

Comment: This study was limited by the bias inherent to anyretrospective analysis or small case series. Although the numberof patients is ample, the smaller size makes the use of mean and