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

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