Cerebral edema in DKA

(Redirected from Cerebral Edema in DKA)

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 Na to rise with therapy
  • Severe acidosis
  • Overaggressive fluid resuscitation is NOT a risk factor

Clinical Features

  • Begins 6-12hr after onset of therapy or may begin before initiation of treatment or up to 48h afterward
    • Many appear to be improving from their DKA before deteriorating from cerebral edema
  • Premonitory symptoms:

Differential Diagnosis

Hyperglycemia

Evaluation

  • Stat head CT (non-contrast)

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 PICU and neurosurgery

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 sub-clinical 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

Authors:

Ross Donaldson