A rare but serious complication in DKA patient and line of management, including competing between 3%Nacl and mannitol

1. CEREBRAL EDEMA IN DKA

2. CEREBRAL EDEMA IN DKA
 DKA mortality rate 0.15 to 0.51 %
 Incidence of CEDKA 0.5% to 1%
 Mortality rate due to cerebral edema in DKA ( 60% – 90 % )
 10% to 25% of survivors of cerebral edema have significant residual morbidity
Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State: A Consensus Statement from the International Society for Pediatric and
Adolescent Diabetes,2017
Joseph I. Wolfsdorfa , Nicole Glaserb , Michael Agusc , Maria Fritschd , Ragnar Hanase , Arleta Rewersf , Mark A. Sperlingg , Ethel
Codnerh

3. RARE COMPLICATIONS OF PEDIATRIC DIABETIC KETOACIDOSIS
SHARA R BIALO, SUNGEETA AGRAWAL, CHARLOTTE M BONEY, AND JOSE BERNARDO QUINTOS, WORLD J DIABETES. 2015 FEB 15; 6(1): 167–174.
PUBLISHED ONLINE 2015 FEB 15. DOI: 10.4239/WJD.V6.I1.167

4. Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State: A Consensus Statement from the International Society for Pediatric and Adolescent Diabetes,2017
Joseph I. Wolfsdorfa , Nicole Glaserb , Michael Agusc , Maria Fritschd , Ragnar Hanase , Arleta Rewersf , Mark A. Sperlingg , Ethel Codnerh

5. DIAGNOSTIC OF CEREBRAL EDEMA :
 Abnormal motor or verbal response to pain
 Decorticate or decerebrate posture
 Cranial nerve palsy
 Abnormal respiratory patterns (grunting, tachypnoea, apnoea, Cheyne-Stokes respiration).
Cushing’s Triad +
bradycardia and HTN

6. CEREBRAL EDEMA RISK FACTOR
Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State: A Consensus Statement from the International Society for Pediatric and Adolescent Diabetes,2017
Joseph I. Wolfsdorfa , Nicole Glaserb , Michael Agusc , Maria Fritschd , Ragnar Hanase , Arleta Rewersf , Mark A. Sperlingg , Ethel Codnerh
risk factors at diagnosis or during treatment of DKA:
 Greater low pCo2 at presentation after adjusting for
degree of acidosis
 Increased BUN at presentation
 Hco3 treatment for correction of acidosis
 A marked early decrease in serum effective osmolality
 An attenuated rise in serum sodium concentration or an
early fall in glucose-corrected sodium during therapy
 Greater volumes of fluid given in the first 4 hours
 Administration of insulin in the first hour of fluid
treatment
Demographic factors :
 Younger age
 New onset diabetes
 Longer duration of
symptoms

7. MAJOR CRITERIA
 Altered mentation, fluctuating level of consciousness after initiation of therapy
 Changes in pupillary response Or other CN palsy (especially III, IV, and VI)
 Sustained and inappropriate bradycardia (decrease >20 beats/min)not attributable to improved
intravascular volume or sleep state
 Abnormal respiratory patterns (grunting, tachypnoea, apnoea, Cheyne-Stokes
respiration).
 Decrease SpO2
 Rapidly rising serum Na
 Age-inappropriate incontinence

8. MINOR CRITERIA
 vomiting
 headache
 Irritability ,lethargy, difficult to aroused from sleep ( if not explained by Hx
of sleep deprivation)
 Increase BP ( DBP > 90 mmHg)

9. WHEN TO START TREATMENT ?
 If a child with RF (age<5, sever acidosis, 1st time DKA) + 1 or more
of miner criteria
 Any child present with DKA + 2 or more of miner criteria or any
major

10. MANAGEMENT
 Decrease ICP :
 Reduce IVF rate .
 0.5–1 g/kg of mannitol IV over 10–15 min, to be repeated if there is no initial response in 30
min to 2 h
 Hypertonic saline (3%) 2.5–5 mL/kg, over 10–15 min, if there is no initial response to mannitol.
 Other
 Elevate the head of the bed to 30 degrees and keep the head in the midline position
 Intubate and Hyperventilation
 Imaging study to rule out other pathologies
ISPAD Clinical Practice Consensus Guidelines 2017
International Society for Pediatric and Adolescent Diabetes (ISPAD)

11.  REVIEW : ESPE/LWPES consensus statement on diabetic
ketoacidosis in children and adolescents D B Dunger, M
A Sperling, C L Acerini, D J Bohn, D Daneman, T P A
Danne, N S Glaser, R Hanas, R L Hintz, L L Levitsky, M O
Savage, R C Tasker, J I Wolfsdorf
Arch Dis Child 2004;89:188–194. doi:
10.1136/adc.2003.044875

12. Increasing use of hypertonic saline over mannitol in the
treatment of symptomatic cerebral edema in pediatric diabetic
ketoacidosis: an 11-year retrospective analysis of mortality*.
AU Decourcey DD, Steil GM, Wypij D, Agus MS
SO Pediatr Crit Care Med. 2013 Sep;14(7):694-700.

13.  Use of mannitol as a sole agent
decreased from 98% to 49%
 3% hypertonic saline as a sole
agent increased from 2% to 39%,
 combined therapy increased from
0% to 10%.

15. MORTALITY INCREASE
 3% hypertonic saline alone was
associated with a higher mortality
than mannitol alone (adjusted odds
ratio, 2.71 [95% CI, 1.01-7.26]) in
patients treated for cerebral edema.
 Similar results were obtained after
adjustment for the propensity to
receive hypertonic saline (adjusted
odds ratio, 2.33 [95% CI, 1.07-5.07])
 in the subset of subjects receiving
mechanical ventilation (adjusted
odds ratio, 3.27 [95% CI, 1.12-9.60]).

16. ISPAD CLINICAL PRACTICE CONSENSUS GUIDELINES 2014