Cerebral edema in DKA: Difference between revisions
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*Almost all affected patients are <20yr <ref>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.</ref> | *Almost all affected patients are <20yr <ref>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.</ref> | ||
*Associated with initial bicarb level; not rate of glucose drop | *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 <ref> Kuppermann, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018;378:2275-87</ref> | |||
===Risk Factors=== | ===Risk Factors=== | ||
Revision as of 03:14, 11 August 2018
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:
- Headache
- Incontinence
- Seizure
- Acute Mental Status Change
- Signs of herniation
Differential Diagnosis
Hyperglycemia
- Physiologic stress response (rarely causes glucose >200 mg/dL)
- Diabetes mellitus (main)
- Hemochromatosis
- Iron toxicity
- Sepsis
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%
- Treat noncardiogenic pulmonary edema, if present
- Consult PICU and neurosurgery
Disposition
Admit PICU/ICU
See Also
References
- ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
- ↑ 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.
- ↑ Kuppermann, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018;378:2275-87
- ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5