Monitor mental status in patients with diabetic ketoacidosis (DKA) during fluid and electrolyte replacement
Monitor mental status in patients with diabetic ketoacidosis (DKA) during fluid and electrolyte replacement: Excerpt from Avoiding Common Pediatric Errors
Author:
Mindy Dickerman, MD
What to Do - Gather Appropriate Data
Cerebral edema is the most feared complication of DKA in children. Clinically apparent cerebral edema occurs in 1% of childhood DKA. One third to
one half of children who develop cerebral edema as a consequence of DKA
die and another one-third suffer severe permanent neurologic disability. It is
unclear if asymptomatic or subclinical cerebral edema occurs commonly in
pediatric DKA or if it is present prior to the initiation of treatment. Cerebral
edema is more commonly seen in children presenting with severe DKA, a
new onset type 1 diabetic, younger age, and a child with longer duration of
symptoms prior to treatment.
A number of possible mechanisms may contribute to cerebral edema in
DKA. There is uncertainty about whether the pathophysiology is a result
of vasogenic edema or cytotoxic edema. Some studies have suggested that
cerebral hypoperfusion and subsequent reperfusion may play a role in the
pathogenesis of cerebral edema. It is thought the reperfusion, in addition to
thebreakdownoftheblood–brainbarrierendothelium,causesvasodilatation
and vasogenic edema. Other studies have proposed the edema formation is
due to cytotoxic edema from increased brain osmolality where, in a chronic
hyperosmolar state due to hyperglycemia, cerebral cells compete with the
osmotic force of serum by storing intracellular osmoles.
Clinically, significant cerebral edema may develop at any time during
the first 24 hours of treatment. The diagnosis of this complication must be
based on clinical bedside criteria. Children may present with abnormal motor or verbal response to pain, decorticate or decerebrate posturing, cranial
nerve palsies, an abnormal neurogenic respiratory pattern, altered mentation, sustained bradycardia, vomiting, headache, and/or lethargy. Because
the symptoms can be vague, it is critical to have a high index of suspicion for
cerebral edema.
A child with DKA should be cared for in a hospital environment with
an experienced nursing staff and where frequent neurologic evaluations can
be performed. The treatment of cerebral edema should be treated as soon
as it is suspected and should not be delayed in order to obtain a computed
tomography scan. The rate of intravenous fluid should be reduced. Intravenous mannitol should be administered at a dose of 0.5 to 1 g/kg over 20
minutes. Intubation may be necessary for a patient with impending respiratory failure or neurologic compromise.
Suggested Readings
AgusMS,WolfsdorfJI.Diabeticketoacidosisinchildren. PediatrClinNorthAm.2005;52:1147–
1163.
Glaser NS, Wootton-Gorges SL, Marcin JP, et al. Mechanism of cerebral edema in children
with diabetic ketoacidosis. J Pediatr. 2004;145:164–171.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Diabetic Ketoacidosis
More Medical Textbooks Online about Diabetic Ketoacidosis
Review other book chapters online related to Diabetic Ketoacidosis:
Medical Books Excerpts
- Diabetes Mellitus
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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» Next page: Remember that the treatment of patients with diabetic ketoacidosis (DKA) is dependent upon theprovision of insulin (Avoiding Common Pediatric Errors)
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