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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*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>
 
*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  
 +
 +
===Risk Factors===
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#Age <5yo
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##Rare in >20yo
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#Severe hyperosmolality
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#Failure of Na to rise w/ therapy
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#Severe acidosis
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#Overaggressive fluid resuscitation is NOT a risk factor
  
 
==Clinical Features==
 
==Clinical Features==
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*[[Mental Status Change]] / [[Seizure]]  
 
*[[Mental Status Change]] / [[Seizure]]  
  
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===Diagnosis===
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*Begins 6-12hr after onset of therapy
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*Many appear to be improving from their DKA before deteriorating from cerebral edema
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*Premonitory symptoms:
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**HA, declining mental status, sz, respiratory arrest
 
==Differential Diagnosis==
 
==Differential Diagnosis==
  
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*Noncardiogenic pulmonary edema
 
*Noncardiogenic pulmonary edema
  
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*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.
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*Fluid restriction - decrease the IVF infusion rate by 30%
 
==Disposition==
 
==Disposition==
 
Admit
 
Admit

Revision as of 08:10, 29 April 2014

Background

  • Almost all affected pts are <20yr [1]
  • Associated with initial bicarb level; not rate of glucose drop

Risk Factors

  1. Age <5yo
    1. Rare in >20yo
  2. Severe hyperosmolality
  3. Failure of Na to rise w/ therapy
  4. Severe acidosis
  5. Overaggressive fluid resuscitation is NOT a risk factor

Clinical Features

Diagnosis

  • Begins 6-12hr after onset of therapy
  • Many appear to be improving from their DKA before deteriorating from cerebral edema
  • Premonitory symptoms:
    • HA, declining mental status, sz, respiratory arrest

Differential Diagnosis

Workup

Management

  • Treatment should be performed in conjunction with primary team recommendations[2]
  • Mannitol IV 1-2gm/kg OR
  • 3% NS 5-10mL/kg over 30min
  • Noncardiogenic pulmonary edema
  • 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%

Disposition

Admit

See Also

Sources

  1. 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.
  2. 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.