Cerebral edema in DKA: Difference between revisions

 
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==Background==
==Background==
*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>
*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>
*[[Cerebral edema in DKA|Cerebral edema]]
*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>
*Almost all affected pts 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  
**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
*Age <5yo
#Severe hyperosmolality
*Severe hyperosmolality
#Failure of Na to rise w/ therapy
*Failure of sodium to rise with therapy
#Severe acidosis
*Severe [[acidosis]]
#Overaggressive fluid resuscitation is NOT a risk factor
*Previous episodes of DKA
*Late presentation for medical evaluation
*Overaggressive fluid resuscitation is ''NOT'' a risk factor


==Clinical Features==
==Clinical Features==
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*Premonitory symptoms:
*Premonitory symptoms:
**[[Headache]]  
**[[Headache]]  
**Incontinence  
**[[urinary incontinence|Incontinence]]
**Acute [[Mental Status Change]] / [[Seizure]]
**[[Seizure]]
**Signs of herniation
**Acute [[mental status changes]]
**Signs of [[herniation Syndromes|herniation]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Hyperglycemia DDX}}


==Workup==
==Evaluation==
*Stat [[CT brain|head CT]] (non-contrast)
*Capillary glucose measurement to rule out [[hypoglycemia]] as the cause of altered mental status


==Management<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>==
==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
*Head of bed at 30 degrees
*Stat head CT (non-contrast)
*[[Mannitol]] 0.5-1gm/kg IV bolus over 20 minutes
*Mannitol 0.5-1gm/kg IV bolus over 20 minutes
**Give a repeat does if there is an inadequate response
**Give a repeat does if there is an inadequate response
**If 2 doses of mannitol are ineffective, consider 3% saline 10mL/kg over 30min
**If 2 doses of mannitol are ineffective, consider 3% saline 10mL/kg over 30min
*Fluid restriction - decrease the IVF infusion rate by 30%
*Fluid restriction - decrease the IVF infusion rate by 30%
**Treat noncardiogenic [[pulmonary edema]], if present
**Treat noncardiogenic [[pulmonary edema]], if present
*Consult PICU and neurosurgery
*Consult neurosurgery (and PICU/ICU as appropriate)


==Disposition==
==Disposition==
Admit ICU
*Admit PICU/ICU


==See Also==
==See Also==
{{Diabetes see also}}
*[[Diabetes mellitus (main)]]
*[[DKA]]
*[[DKA (Peds)]]


==Sources==
==References==
*Tintinalli 7th edition
<references/>
<references/>


[[Category:Endo]]
[[Category:Endocrinology]]
[[Category:Neuro]]
[[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

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