Cerebral edema in DKA: Difference between revisions
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==Background== | ==Background== | ||
*Almost all affected | *1% of patients with DKA<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</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 subclinical 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 | ||
**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 <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=== | ||
*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== | ==Clinical Features== | ||
* | *Begins 6-12hr after onset of therapy or may begin before initiation of treatment or up to 48h afterward | ||
*[[Headache]] | **Many appear to be improving from their DKA before deteriorating from cerebral edema | ||
*Incontinence | *Premonitory symptoms: | ||
*[[ | **[[Headache]] | ||
**[[urinary incontinence|Incontinence]] | |||
**[[Seizure]] | |||
**Acute [[mental status changes]] | |||
**Signs of [[herniation Syndromes|herniation]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Hyperglycemia DDX}} | |||
== | ==Evaluation== | ||
*Stat [[CT brain|head CT]] (non-contrast) | |||
*Capillary glucose measurement to rule out [[hypoglycemia]] as the cause of altered mental status | |||
==Management | ==Management<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>== | ||
*Head of bed at 30 degrees | |||
*Mannitol | *[[Mannitol]] 0.5-1gm/kg IV bolus over 20 minutes | ||
*3% | **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 neurosurgery (and PICU/ICU as appropriate) | |||
==Disposition== | ==Disposition== | ||
Admit | *Admit PICU/ICU | ||
==See Also== | ==See Also== | ||
*[[Diabetes mellitus (main)]] | |||
*[[DKA]] | *[[DKA]] | ||
*[[DKA (Peds)]] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Endocrinology]] | |||
[[Category:Neurology]] | |||
[[Category:Critical Care]] | |||
Latest revision as of 00:19, 3 October 2019
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
- 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 changes
- 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)
- 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%
- Treat noncardiogenic pulmonary edema, if present
- Consult neurosurgery (and PICU/ICU as appropriate)
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 subclinical 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