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Diabetic Ketoacidosis Related Cerebral Edema

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Diabetic Ketoacidosis Related Cerebral Edema, DKA related Cerebral Edema

  • See Also
  1. Diabetic Ketoacidosis
  2. Diabetic Ketoacidosis Management in Adults
  3. Diabetic Ketoacidosis Management in Children
  • Epidemiology
  1. Incidence: 0.5 to 1% of pediatric Diabetic Ketoacidosis patients
  • Pathophysiology
  1. Osmotic Theory (historically accepted theory)
    1. Prolonged Hyperglycemia results in hyperosmolarity
    2. Rapid osmolar shift occurs with large fluid bolus
    3. However, fails to explain Cerebral Edema in DKA patients who did not receive IV fluids
  2. Vasogenic Theory (more recent theory gaining acceptance)
    1. Free fluid crosses the brain barrier more easily in severe acidosis and Dehydration
  • Risk Factors
  1. Younger children (<5 years old, and esp. age <3 years)
  2. New onset Diabetes Mellitus
  3. Longer duration of DKA symptoms
  4. Severe Metabolic Acidosis
  5. Rapid hydration has been postulated as cause
    1. Precautions regarding fluid rate and amount are standard of care in Diabetic Ketoacidosis management (see below)
    2. However large study did not show an association with fluid rate or amount
    3. Glaser (2001) N Engl J Med 344(4): 264-9 [PubMed]
  6. Insulin given in first hour of DKA Management
  7. Elevated Blood Urea Nitrogen
  8. Decreased pCO2
  9. Bicarbonate administration
  10. Failure of Serum Sodium to rise despite correction of Hyperglycemia
  • Symptoms
  • Initial Symptoms
  1. Headache
  2. Refractory Vomiting
  3. Hypertension
  4. Bradycardia
  5. Lethargy
  • Signs
  1. Neurologic deficits (esp. Altered Level of Consciousness)
  2. Vital Sign abnormalities
    1. Bradycardia
    2. Hypertension
  • Precautions
  • Children under age 5 years old with DKA
  1. Avoid large fluid boluses beyond initial 10-20 cc/kg if at all possible
  2. Avoid dropping Serum Osmolality (calc) >3 mOsms/hour
  • Management
  1. See Diabetic Ketoacidosis Management in Adults
  2. See Diabetic Ketoacidosis Management in Children
  3. Emergent management of acute cerebral edema
    1. Raise the head of bed
    2. Administer Hypertonic Saline 3% (5 ml/kg) OR Mannitol IV (0.5 to 1 mg/kg)
  • Prognosis
  1. Mortality: 21-24% (50% in some studies)
  2. Persistent vegatative state in up to one third of surviving children
  • References
  1. Aurora and Menchine in Herbert (2014) EM:Rap 14(1): 10-11
  2. Fahlsing and Ponce (2024) Crit Dec Emerg Med 38(3): 18-9