Subscribe to Resus
Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!
Register Now:
Cerebral oedema is the most feared complication in children presenting with Diabetic Ketoacidosis (DKA). It occurs in about 1% of cases but has a mortality rate of up to 90% (Waldorf J et al Diabetes Care 2006; 29:1150-9). Patients will have a decreased conscious state and may also have cranial nerve palsies, headache and/or bradycardia and hypertension.
Its incidence has remained the same since it was described in 1936 and although we have clues as to what may contribute to it, and we know that some patients have subclinical cerebral oedema at presentation(Krane et al NEJM 1985;312:1147-51), we still can’t predict who will get it, nor greatly affect its high rate of mortality.
There are theories of causative factors, most of which are vasogenic or osmotically based, but there is really no great evidence out there. The studies are small or retrospective, or both.
WHAT CAUSES IT? – THEORETICALLY
One theory relates to osmolytes accumulating in brain cells. These are the compounds that maintain normal cell volumes. As extracellular osmolality decreases rapidly with treatment, water flows rapidly onto these cells causing the brain to swell.
Another theory relates to Na+ / H+ exchanger, such that a correction of acidosis results in Na and water passing onto the brain cells, resulting in oedema.
How much has been proven to be the actual mechanism? By my reading, not much.
WHAT CAUSES IT? – IN PRACTICAL TERMS
We believe that the following increase the chance of developing cerebral oedema:
- Newly diagnosed diabetes
- Duration of symptoms
- Rapid change in Osmolality (2xNa + U + Glc): – ie rapid decrease in Glucose and a decrease in Sodium
- Initial pH < 7.1……………. and in more recent studies (Glaser N et al NEJM 2001;344:264-269)
- Decrease in CO2
- Increased Urea
- If treated with Bicarbonate
WHAT DOES THIS MEAN IN TERMS OF TREATMENT?
FLUIDS: If the patient is hypotensive and crashing then fluid resuscitation is necessary. No question about it. However, how much we give may matter. In some of the work published there is an indication that more than 40ml/kg given over the first 4 hours may predispose to cerebral oedema.
We seem to be conditioned to give 20ml/kg to every child. My approach is a little less aggressive. I aim at 5-10ml/kg. I then review and give it a little time ( that may only be minutes) before more fluids are given. The point is, unless the child is crashing we don’t have to give large volumes, we can pull back a little.
INSULIN AND GLUCOSE LEVELS: Large drops in glucose, decrease osmolality. If this is done rapidly, it can, according to the osmotic theory cause cerebral oedema. Hoorn et al (J pediatr 2007:150: 467-473), found that a drop in osmolality from 304 + 5 to 290 + 5, was associated with increased cerebral oedema.
WHAT SHOULD WE TAKE AWAY FROM ALL OF THIS AND WHAT SHOULD WE DO?
The evidence isn’t great. What we see is that the more acidotic you are, the more deranged your electrolytes, the more abnormal your physiology, the worst you do. The sicker kids did badly. Common sense.
Firstly it’s important to say that it’s very rare that you will see one of these cases unless you are working in an ED that sees lots of kids. That’s why its even more important to know what to do, because its not that frequent.
If a child is sick and haemodynamically crashing, then I give fluids. I don’t give 20ml/kg of normal saline right away. I will give 5-10ml/kg and then review. I can always give more if needed.
I don’t give a bolus of insulin, I start and infusion an wait for gentle lowering of the blood sugar i.e.., < 5mmol/L drop per hour. Things improve over hours. Nothing needs to happen quickly here.
If I think a child has cerebral oedema, mannitol 1g/kg IV is the treatment of choice. You must discuss these patients with endocrine and ICU. If the conscious state deteriorates to the point where protection of the airway is needed, or if airway control is necessary to paralyse and lower intracranial pressure( if this indeed assists in this case), then beware not to hyperventilate the patient. Hypocapnia from mechanical ventilation has been associated with this condition(Glaser N et al NENM 2001;344:264-269)
Cerebral oedema a difficult condition to treat and the outcome is not good. We don’t really know if our treatment contributes to the development. However, we need to do everything we can to minimise any possibility of causing the problem.
Peter Kas
83 Comments
Leave a Comment
Subscribe for FREE regular updates in your inbox.
Get notified on all upcoming Conferences PLUS our Webcasts, Education Newsletters, and more!
Popular Posts
Paediatric Pearls
Treating the Hypoxic COVID-19 Patient: Can low flow systems be improved?
Cardiogenic Shock: Which Vasopressor to use
The U wave and the ECG: Don’t miss this
Is Ventricular Bigeminy Benign? Which Patients Need treatment?
5 Things you Must do when Patients Present with Syncope
11 Things to Maximise Adult Cardiac Resuscitation
Isn’t hyperventilation a strategy to reduce ICP by decreasing blood volume in cerebral veins? If so, how is hyperventilation harmful in dka in children?
Hyperventilation has been a strategy used to decrease ICP by directly decreasing PCO2 and raising vasoconstriction–in the past. You are correct. However this hyperventilation is done very short term and in special circumstances i.e.., in the acute deteriorating patient where we are quickly reducing pressures prior to theatre. We now ventilate to normal CO2 levels in all patients for a number of reasons:
1. Prolonged hyperventilation when discontinued, allowing normocapnia to be restored quickly results in a REBOUND phenomenon causing an INCREASE in CEREBRAL BLOOD FLOW and thus an increase in intracranial pressure.
2. Overzealous hyperventilation at pCO2 around 20-25mmHg can induce CEREBRAL ISCHAEMIA via vasoconstriction.
3. No study has shown any benefit in terms of survival with hyperventilation, in fact the contrary is shown.
Excellent pieces. Keep writing such kind of information on your
blog. Im really impressed by it.
Hi there, You have performed an incredible job. I’ll certainly digg it
and individually recommend to my friends. I am confident they will be benefited from this site.
I am sure this article has touched all the internet users,
its really really pleasant paragraph on building up new weblog.
WOW just what I was searching for. Came here by searching
for natural yeast infection treatment
Feel free to visit my homepage heal eczema
I have been absent for some time, but now I remember
why I used to love this website. Thank you, I will try and check back more often. How
frequently you update your website?
Here is my blog post :: wrinkle skin care
It’s actually a nice and helpful piece of information. I am happy that you just
shared this useful info with us. Please stay us up to date
like this. Thanks for sharing.
Have a look at my web-site high quality treatment, http://www.hjzzj.com,
Amazing! Its actually awesome article, I have got much clear idea about from this article.
my blog: exercise for sciatic pain relief
Very descriptive blog, I enjoyed that bit. Will there
be a part 2?
Feel free to visit my page – try hemp
If you are going for finest contents like myself,
only go to see this web site everyday as it presents feature contents, thanks
Feel free to surf to my web site … natural yeast infection treatment
Aw, this was a really good post. Finding the time and actual effort
to create a very good article? but what can I say?
I put things off a whole lot and never seem to get anything done.
Check out my page … stop smoking (Sharyn)
fantastic points altogether, you simply won a new reader.
What would you suggest in regards to your post that you just made a few days
ago? Any certain?
my page – benefits of hemp seed oil (http://23.95.102.216/viewtopic.php?id=363915)
Thanks for sharing excellent informations. Your website is so cool.
I’m impressed by the details that you have on this blog.
It reveals how nicely you perceive this subject. Bookmarked this web page,
will come back for extra articles. You, my friend, ROCK!
I found simply the info I already searched all over the place and just could not come across.
What a great website.
Visit my blog post … pubic hair removal (http://www.mhes.tyc.edu.tw)
Truly when someone doesn’t understand then its
up to other visitors that they will assist, so here it occurs.
Also visit my page … organic and natural skin care
Because the admin of this web page is working, no question very rapidly it will be famous, due to its quality contents.
Here is my webpage seed contains
I’m not sure why but this site is loading extremely slow for
me. Is anyone else having this problem or is it a problem on my end?
I’ll check back later and see if the problem still exists.
Also visit my web blog – buy seeds online
Hello There. I found your weblog the use of msn. This is a really well written article.
I’ll be sure to bookmark it and come back to read extra of your helpful info.
Thank you for the post. I’ll definitely comeback.
Also visit my web-site: anti aging skin care tips
I couldn’t resist commenting. Exceptionally well written!
Feel free to visit my web page – healthy food
My family members every time say that I am wasting my time here at net, except
I know I am getting knowledge daily by reading such pleasant articles or reviews.
My homepage cannabis vodka
Hey there! I’ve been following your blog home remedies for quit smoking a long time now
and finally got the bravery to go ahead and give you a shout out from Humble Texas!
Just wanted to tell you keep up the great job!
Hello there, I discovered your website via Google whilst looking for a comparable matter, your website got here up, it appears
to be like great. I’ve bookmarked it in my google bookmarks.[X-N-E-W-L-I-N-S-P-I-N-X]Hi there,
simply changed into aware of your blog via Google, and
found that it is really informative. I am gonna watch out for brussels.
I will appreciate in the event you continue this
in future. Lots of other people can be benefited from your writing.
Cheers!
Also visit my website: coping with eczema (patinajeartistico.es)
Really nice layout and good content material, absolutely nothing else we need :D.
My web site; eczema remedies
Nice read, I just passed this onto a colleague who was doing a little research on that.
And he actually bought me lunch as I found it for him smile So let me rephrase that:
Thank you for lunch!
Take a look at my site – growing weed; forum.m2clasic.ro,
Superb blog! Do you have any tips and hints for aspiring writers?
I’m planning to start my own blog soon but I’m a little lost on everything.
Would you suggest starting with a free platform like WordPress
or go for a paid option? There are so many options out there that I’m completely
overwhelmed .. Any recommendations? Thank you!
my website :: facial skin care routine (https://prettypeople.club/)
My partner and i still can not quite assume that I
could be one of those studying the important recommendations found on your blog.
My family and I are sincerely thankful for your generosity and for
providing me the chance to pursue our chosen profession path.
Thanks for the important information I got from your web site.
My blog post: healthy food
This is a topic that is close to my heart…
Take care! Where are your contact details though?
Also visit my website: indoor growing mini-course (163.30.42.16)
I love your writing style really enjoying this internet site.
My site how to remove acne scars
Just wanna comment that you have a very nice site, I
love the layout it really stands out.
my page; adult acne
Right here is the perfect webpage for anybody who wishes to find out about this
topic. You understand a whole lot its almost hard to argue
with you (not that I actually will need to…HaHa).
You certainly put a brand new spin on a topic that’s been discussed for
decades. Wonderful stuff, just excellent!
Here is my web blog: daily skin care
I know this site provides quality based articles
or reviews and additional stuff, is there any other site which gives such data in quality?
my website – testosterone levels
I just wanted to develop a simple note in order to express gratitude to
you for the amazing steps you are giving on this
website. My considerable internet look up has at the end of the day been honored with awesome know-how to exchange with my neighbours.
I would admit that most of us website visitors actually are quite fortunate
to live in a fabulous site with many brilliant people with insightful guidelines.
I feel extremely lucky to have encountered the web page and look forward to so many more exciting times
reading here. Thanks a lot once more for everything.
Also visit my webpage :: cannabis seeds – 163.30.42.16 –
What’s up, I log on to your new stuff regularly.
Your story-telling style is awesome, keep up the good work!
My webpage testosterone center
Does your site have please a woman contact page?
I’m having a tough time locating it but, I’d like to send you an e-mail.
I’ve got some creative ideas for your blog you might be interested
in hearing. Either way, great blog and I look forward to seeing it develop over
time.
Thank you for your website post. Thomas and I are saving to
get a new book on this subject and your short article has made all of us to
save money. Your notions really answered all our
inquiries. In fact, more than what we had recognized
ahead of the time we came upon your wonderful blog.
My partner and i no longer have doubts and also a troubled mind because you have
totally attended how to get healthy skin (Anja) each
of our needs in this article. Thanks
Hey there! I’ve been following your blog for some time now and finally got the bravery to go ahead and give you a shout out from Austin Texas!
Just wanted to say keep up the great work!
Here is my web blog – build muscle
Highly descriptive blog, I liked that bit.
Will there be a part 2?
my blog – low libido
Hey I know this is off topic but I was wondering if you knew of any widgets I could add to my blog that automatically tweet my newest twitter updates.
I’ve been looking for a plug-in like this for quite some
time and was hoping maybe you would have some experience with something like this.
Please let me know if you run into anything. I truly enjoy reading your blog and I look
forward to your new updates.
my web site :: drug abuse treatment
That is very attention-grabbing, You’re an excessively skilled blogger.
I have joined your feed and look forward to seeking extra of your magnificent post.
Additionally, I have shared your web site in my social networks
Have a look at my blog: stop smoking weed today
It’s actually a great and useful piece of information. I’m happy that you just shared this helpful info with us.
Please keep us informed like this. Thank you for
sharing.
Also visit my web-site – impact carbs
Hi my friend! I want to say that this post is amazing, nice written and come with approximately all
important infos. I would like to see extra posts like
this .
Feel free to surf to my web-site quit smoking
remedies – https://www.mhes.tyc.edu.tw/,
I went over this website and I think you have a lot of superb info, saved to favorites (:
.
My website :: hormone levels
Simply wish to say your article is as astonishing. The clearness in your post is just great and i can assume you are an expert on this subject.
Well with your permission allow me to grab your feed to keep up to date with forthcoming post.
Thanks a million and please carry on the enjoyable work.
Thanks for finally writing about > DKA and Cerebral Oedema – Do we really know the cause?
– Resus < Liked it!
Cool blog! Is your theme custom made or did you download it from somewhere?
A theme like yours with a few simple adjustements would really make my blog stand out.
Please let me know where you got your theme. Cheers
Feel free to visit my page growing weed indoorshave
Undeniably believe that which you stated.
Your favorite reason appeared to be on the net the simplest thing to be
aware of. I say to you, I definitely get annoyed while people consider worries that they plainly do not know about.
You managed to hit the nail upon the top as well as defined out the whole thing without
having side-effects , people could take a signal.
Will likely be back to get more. Thanks
My webpage :: cholesterol lowering drugs
Amazing! Its truly awesome piece of writing, I have got much clear idea concerning from this paragraph.
my site – cure eczema
I saw a lot of website but I think this one contains
something special in it.
Stop by my blog: affordable treatment
Just desire to say your article is as astounding.
The clarity in your post is just excellent and that i could think you are
a professional foods rich in omega 3 fatty acids this subject.
Well together with your permission let me to take hold
of your RSS feed to stay updated with coming near near post.
Thanks 1,000,000 and please continue the
enjoyable work.
Paragraph writing is also a fun, if you be
acquainted with afterward you can write otherwise it is
difficult to write.
Feel free to surf to my web page :: eczema heals
I am impressed with this web site, very I am a big fan.
Have a look at my blog :: lower blood cholesterol
It’s enormous that you are getting thoughts
from this paragraph as well as from our dialogue made at this place.
my web page substance abuse treatment
Hi there, yup this article is truly nice and I have learned lot of things from it on the topic of blogging.
thanks.
Stop by my site … http://www.vstromturkiye.com
I’d incessantly want to be update on new articles on this web site, saved
to favorites!
Also visit my web blog – getting treatment
It’s really a nice and helpful piece of information. I am satisfied that you simply
shared this useful information with us. Please stay us up to
date like this. Thanks for sharing.
my blog skin care
I am truly grateful to the holder of this website who has shared this impressive paragraph at
at this time.
Have a look at my page :: https://patimood.net/index.php?action=profile;u=132262
Hello there! This article couldn?t be written any better!
Looking at this article reminds me of my previous roommate!
He continually kept talking about this. I am going to forward
this article to him. Pretty sure he’ll have a very good read.
Thanks for sharing!
My web page – sleep hygiene practices
I like this site because so much useful material on here :D.
Feel free to surf to my web site: fish oil
Have you ever considered publishing an ebook or guest authoring on other websites?
I have a blog based on the same subjects you discuss and would really
like to have you share some stories/information. I know my viewers would appreciate your work.
If you’re even remotely interested, feel free fasting to lose weight shoot me an email.
Simply wanna comment on few general things, The website style is perfect, the content material is really wonderful :
D.
Also visit my web blog :: Toni
If some one desires to be updated with newest technologies afterward he must be pay a visit this web page and be up to date everyday.
Visit my web blog: weed indoorshave
Wonderful beat ! I wish to apprentice while you amend your web
site, how can i subscribe for a blog website?
The account helped me a acceptable deal. I had been a little bit acquainted of
this your broadcast offered bright clear concept
Here is my website – seed bank
As I web-site possessor I believe the content material here is rattling magnificent ,
appreciate it for your efforts. You should keep it up forever!
Best of luck.
Also visit my web page – weed doctor websitehope
It’s not my first time to pay a quick visit this web page, i am visiting this
web page dailly and get fastidious data from here every day.
My blog – home remedies for quit smoking
I am constantly looking online for articles that can aid
me. Thanks!
Feel free to surf to my web page … 23.95.102.216
It’s remarkable to go to see this site and reading the views of
all friends concerning this paragraph, while I am also zealous of
getting familiarity.
my homepage – cannabis vodka
Hello i am kavin, its my first occasion to commenting anywhere, when i
read this post i thought i could also create comment due to this brilliant piece of writing.
my web site tooth pain
I am truly grateful to the owner of this site who has shared this great piece of writing at at this time.
my web blog – facial skin care tips
I always was concerned in this topic and still
am, thank you for posting.
Also visit my web site :: https://truckersmp.hu/index.php?action=profile;u=100457
This design is incredible! You definitely know
how to keep a reader entertained. Between your wit and your
videos, I was almost moved to start my own blog (well, almost…HaHa!) Wonderful job.
I really enjoyed what you had to say, and more than that, how you
presented it. Too cool!
My homepage; wrist pain
I am glad to be one of the visitors on this great website (:, thanks for putting up.
Feel free to visit my web blog :: various cannabis
This design is spectacular! You most certainly
know how to keep a reader entertained. Between your wit and your videos,
I was almost moved to start my own blog (well,
almost…HaHa!) Excellent job. I really enjoyed what you had to say, and
more than that, how you presented it. Too cool!
My web blog … hatched seeds
Aw, this was a very nice post. Finding the time and
actual effort to produce a good article? but what can I say?
I put things off a lot and don’t seem to get anything done.
Visit my site :: diet tea
Excellent blog here! Also your site loads up fast! What web host are you using?
Can I get your affiliate link to your host? I wish my
web site loaded up as fast as yours lol
Here is my web blog :: http://23.95.102.216
I almost never leave comments, but i did a few searching and wound up
here DKA and Cerebral Oedema – Do we really know the cause?
– Resus. And I actually do have a couple of questions for you if you don’t mind.
Is it just me or does it look like a few of the comments
come across like written by brain dead folks? 😛 And, if you are
writing on additional online social sites, I would like to follow anything new
you have to post. Would you list of the complete urls of your public sites like your linkedin profile,
Facebook page or twitter feed?
My homepage: growing weed indoors
Please let me know if you’re looking for a writer for your weblog.
You have some really great articles and I believe
I would be a good asset. If you ever want to take some of the load off,
I’d love to write some articles for your blog in exchange for a link back to mine.
Please blast me an email if interested. Regards!
my page; eczema on feet
Hey There. I found your blog using msn. This is a very well
written article. I will be sure to bookmark it and return to read more of your useful information. Thanks for the post.
I will definitely comeback.
Also visit my web site; http://23.95.102.216/viewtopic.php?id=383570
Someone essentially help to make significantly articles I’d state.
This is the very first time I frequented your web page and to this point?
I surprised with the research you made to make this particular post amazing.
Magnificent process!
my webpage :: https://forum.pos.md/index.php?action=profile;u=1148
I like this website because so much useful material on here
:D.
Review my site patimood.net
Thanks for any other wonderful post. The
place else could anyone get that type of info in such an ideal method of writing?
I’ve a presentation subsequent week, and I am at the look for such info.
Here is my web blog; 23.95.102.216
It’s going to be ending of mine day, but before ending I am reading
this enormous paragraph to improve my knowledge.
Feel free to visit my site 163.30.42.16
Hi everybody, here every one is sharing these know-how, thus it’s good to read this webpage, and I used to pay
a visit this web site every day.
Here is my web site – quit smoking home remedies
Thank u for your sharing.Your blog has a unique feature that can make the people who reads become happy.After reading your blog,I feel happy
Great article! We are linking to this great content on our site. Keep up the good writing.
My spouse and I stumbled over here from a different website and thought I might check things out.I like what I see so now i’m following you. Look forward to looking at your web page repeatedly.