Difference between revisions of "Cerebral edema in DKA"

(Created page with "==Background== *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 ede...")
 
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==Background==
 
==Background==
*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>
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*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===
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*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===
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*Age <5yo
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*Severe hyperosmolality
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*Failure of sodium to rise with therapy
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*Severe [[acidosis]]
 +
*Previous episodes of DKA
 +
*Late presentation for medical evaluation
 +
*Overaggressive fluid resuscitation is ''NOT'' a risk factor
  
 
==Clinical Features==
 
==Clinical Features==
*Symptoms:  
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*Begins 6-12hr after onset of therapy or may begin before initiation of treatment or up to 48h afterward
*[[Headache]]  
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**Many appear to be improving from their DKA before deteriorating from cerebral edema
*Incontinence  
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*Premonitory symptoms:
*[[Mental Status Change]] / [[Seizure]]  
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**[[Headache]]  
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**[[urinary incontinence|Incontinence]]
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**[[Seizure]]
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**Acute [[mental status changes]]
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**Signs of [[herniation Syndromes|herniation]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 +
{{Hyperglycemia DDX}}
  
==Workup==
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==Evaluation==
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*Stat [[CT brain|head CT]] (non-contrast)
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*Capillary glucose measurement to rule out [[hypoglycemia]] as the cause of altered mental status
  
==Management==
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==Management<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>==
*Treatment should be performed in conjunction with primary team recommendations<ref>Dunger DB, Sperling MA, Acerini CL, et al. (February 2004). "European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents". Pediatrics 113 (2): e133–40. doi:10.1542/peds.113.2.e133. PMID 14754983.</ref>
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*Head of bed at 30 degrees
*Mannitol IV 1-2gm/kg OR
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*[[Mannitol]] 0.5-1gm/kg IV bolus over 20 minutes
*3% NS 5-10mL/kg over 30min  
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**Give a repeat does if there is an inadequate response
*Noncardiogenic pulmonary edema
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**If 2 doses of mannitol are ineffective, consider 3% saline 10mL/kg over 30min
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*Fluid restriction - decrease the IVF infusion rate by 30%
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**Treat noncardiogenic [[pulmonary edema]], if present
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*Consult neurosurgery (and PICU/ICU as appropriate)
  
 
==Disposition==
 
==Disposition==
Admit
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*Admit PICU/ICU
  
 
==See Also==
 
==See Also==
 +
*[[Diabetes mellitus (main)]]
 
*[[DKA]]
 
*[[DKA]]
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*[[DKA (Peds)]]
  
==Sources==
+
==References==
 
<references/>
 
<references/>
 +
 +
[[Category:Endocrinology]]
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[[Category:Neurology]]
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[[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