2. CEREBRAL EDEMA IN DKA
๏ก DKA mortality rate 0.15 to 0.51 %
๏ก Incidence of CEDKA 0.5% to 1%
๏ก Mortality rate due to cerebral edema in DKA ( 60% โ 90 % )
๏ก 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): 167โ174.
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 :
๏ก Abnormal motor or verbal response to pain
๏ก Decorticate or decerebrate posture
๏ก Cranial nerve palsy
๏ก Abnormal respiratory patterns (grunting, tachypnoea, apnoea, Cheyne-Stokes respiration).
Cushingโs 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:
๏ง Greater low pCo2 at presentation after adjusting for
degree of acidosis
๏ง Increased BUN at presentation
๏ง Hco3 treatment for correction of acidosis
๏ง A marked early decrease in serum effective osmolality
๏ง An attenuated rise in serum sodium concentration or an
early fall in glucose-corrected sodium during therapy
๏ง Greater volumes of fluid given in the first 4 hours
๏ง Administration of insulin in the first hour of fluid
treatment
Demographic factors :
๏ง Younger age
๏ง New onset diabetes
๏ง Longer duration of
symptoms
7. MAJOR CRITERIA
๏ก Altered mentation, fluctuating level of consciousness after initiation of therapy
๏ก Changes in pupillary response Or other CN palsy (especially III, IV, and VI)
๏ก Sustained and inappropriate bradycardia (decrease >20 beats/min)not attributable to improved
intravascular volume or sleep state
๏ก Abnormal respiratory patterns (grunting, tachypnoea, apnoea, Cheyne-Stokes
respiration).
๏ก Decrease SpO2
๏ก Rapidly rising serum Na
๏ก Age-inappropriate incontinence
8. MINOR CRITERIA
๏ก vomiting
๏ก headache
๏ก Irritability ,lethargy, difficult to aroused from sleep ( if not explained by Hx
of sleep deprivation)
๏ก Increase BP ( DBP > 90 mmHg)
9. WHEN TO START TREATMENT ?
๏ก If a child with RF (age<5, sever acidosis, 1st time DKA) + 1 or more
of miner criteria
๏ก Any child present with DKA + 2 or more of miner criteria or any
major
10. MANAGEMENT
๏ก Decrease ICP :
๏ก Reduce IVF rate .
๏ก 0.5โ1 g/kg of mannitol IV over 10โ15 min, to be repeated if there is no initial response in 30
min to 2 h
๏ก Hypertonic saline (3%) 2.5โ5 mL/kg, over 10โ15 min, if there is no initial response to mannitol.
๏ก Other
๏ก Elevate the head of the bed to 30 degrees and keep the head in the midline position
๏ก Intubate and Hyperventilation
๏ก Imaging study to rule out other pathologies
ISPAD Clinical Practice Consensus Guidelines 2017
International Society for Pediatric and Adolescent Diabetes (ISPAD)
11. ๏ก 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;89:188โ194. 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. ๏ก Use of mannitol as a sole agent
decreased from 98% to 49%
๏ก 3% hypertonic saline as a sole
agent increased from 2% to 39%,
๏ก combined therapy increased from
0% to 10%.
14.
15. MORTALITY INCREASE
๏ก 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.
๏ก Similar results were obtained after
adjustment for the propensity to
receive hypertonic saline (adjusted
odds ratio, 2.33 [95% CI, 1.07-5.07])
๏ก in the subset of subjects receiving
mechanical ventilation (adjusted
odds ratio, 3.27 [95% CI, 1.12-9.60]).
Clinically significant cerebral edema usually develops within the first 12 hours after treatment has started, but can occur before treatment has begun 104,206,242-245 or, rarely, may develop as late as 24-48 hours after the start of treatment 104,236,246
Lawrence SE, Cummings EA, Gaboury I, Daneman D. Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr. 2005;146(5):688-692.
Fiordalisi I, Harris GD, Gilliland MG. Prehospital cardiac arrest in diabetic ketoacidemia: why brain swelling may lead to death before treatment. J Diabetes Complications. 2002;16(3):214- 219.