Cerebral edema in DKA

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Background

  • 1% of patients with DKA[1]
  • Almost all affected patients are <20yr [2]
  • Associated with initial bicarb level; not rate of glucose drop
    • Children presenting with higher blood urea nitrogen levels and more severe acidosis are at higher risk

Pathophysiology

  • Thought to be due to cerebral hypoperfusion and less likely osmotic shifts with rapid infusion of IVF's [3]

Risk Factors

  • Age <5yo
  • Severe hyperosmolality
  • Failure of sodium to rise with therapy
  • Severe acidosis
  • Previous episodes of DKA
  • Late presentation for medical evaluation
  • Overaggressive fluid resuscitation is NOT a risk factor

Clinical Features

Differential Diagnosis

Hyperglycemia

Evaluation

  • Stat head CT (non-contrast)
  • Capillary glucose measurement to rule out hypoglycemia as the cause of altered mental status

Management[4]

  • Head of bed at 30 degrees
  • Mannitol 0.5-1gm/kg IV bolus over 20 minutes
    • Give a repeat does if there is an inadequate response
    • If 2 doses of mannitol are ineffective, consider 3% saline 10mL/kg over 30min
  • Fluid restriction - decrease the IVF infusion rate by 30%
  • Consult neurosurgery (and PICU/ICU as appropriate)

Disposition

  • Admit PICU/ICU

See Also

References

  1. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  2. Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, et al. Frequency of subclinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. Apr 2006;7(2):75-80.
  3. Kuppermann, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018;378:2275-87
  4. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5