Diabetic Ketoacidosis in Children: Management

Subscribe to Resus

Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!

  • We respect your privacy
  • This field is for validation purposes and should be left unchanged.

Register Now:

Emcore
Learn More

CEREBRAL OEDEMA: DO WE REALLY KNOW THE CAUSE?

We recently had a child with (diabetic ketoacidosis)DKA in our department and the subject of fluid resuscitation came up. Also the Queensland Government guidelines on the Emergency Management of children with DKA has recently been produced.

I thought it was timely to revisit a blog I wrote in 2014 on the evidence on this topic, as well as set up a teaching module on DKA ( more on this at the end)
Cerebral oedema is the most feared complication in children presenting with 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 even 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 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.

WHAT CAUSES IT? – IN PRACTICAL TERMS

We believe that the following increase the chance of developing cerebral oedema:
1    Newly diagnosed diabetes
2    Duration of symptoms
3    Rapid change in Osmolality (2xNa + U + Glc): i.e., a rapid decrease in Glucose and in Sodium
4    Initial pH < 7.1
……………. and in more recent studies (Glaser N et al NEJM 2001;344:264-269)
5    Decrease in CO2
6    Increased Urea
7    If treated with Bicarbonate

WHAT DOES THIS MEAN IN TERMS OF TREATMENT of DKA?

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 5ml/kg if the child is very unwell and crashing. 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. The recommendations look at tolerating a systolic blood pressure of (70 + 2 x age)mmHg. We must remember that kids don’t have much room, when they decompensate and that hypotension is a late sign. However it is this very group of children that we may be harming. If the blood pressure is OK, leave them be. If you really have to give fluids ( because it is so conditioned that its an automatic reflex), give 1ml/kg and wait.
The usual approach to fluids is to calculate the deficit and ongoing maintenance needs and give over 48 hours.

INSULIN AND GLUCOSE LEVELS

Large rapid drops in glucose, or a rapid decrease in osmolality 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 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 an infusion(after fluids are initiated and probably not before 1-2 hours) and 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/Paediatrics 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, if it occurs, is a difficult condition to treat and the outcomes aren’t good. We don’t really know if our treatment contributes to the development. However, we need to do everything we can, to ensure it doesn’t.

Click below to complete a real time case module on our emcore website online, that will help reinforce the management of DKA.

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

60 Comments

  1. Vickey on 05/10/2021 at 9:01 am

    Hey there would you mind stating which blog platform you’re using?

    I’m going to start my own blog soon but I’m having a tough time
    choosing between BlogEngine/Wordpress/B2evolution and Drupal.
    The reason I ask is because your design seems different then most blogs and I’m looking for something
    unique. P.S Apologies for being off-topic but I had to ask!

  2. Great ? I should certainly pronounce, impressed with your site.
    I had no trouble navigating through all tabs
    as well as related information ended up being truly easy
    how to stop smoking weed (http://www.fotosombra.com.br/agenda/userinfo.php?uid=1270266) do to access.
    I recently found what I hoped for before you know it at
    all. Reasonably unusual. Is likely to appreciate it for those who add forums or something, web site theme .
    a tones way for your client to communicate. Nice task.

  3. meteoritegarden.com on 05/10/2021 at 9:02 am

    I like this web blog it’s a master piece! Glad I noticed this on google.

    my website: diabetic diet – meteoritegarden.com

  4. care personal skin on 05/10/2021 at 9:09 am

    I do trust all of the ideas you have presented on your post.
    They’re really convincing and will certainly work.
    Still, the posts are very quick for novices. Could you please lengthen them a bit from next time?

    Thank you for the post.

    Here is my page … care personal skin

  5. Christin on 05/10/2021 at 9:19 am

    Quality posts is the crucial to be a focus for the users to pay a visit the website, that’s what this site is providing.

  6. term treatment on 05/10/2021 at 9:57 am

    I am really happy to read this website posts which includes tons of helpful data, thanks for
    providing these kinds of data.

    Review my web blog … term treatment

  7. curing sciatica on 05/10/2021 at 9:57 am

    Unquestionably believe that which you stated. Your favorite justification appeared to
    be on the internet the simplest thing to be aware of.

    I say to you, I certainly get irked while people think
    about worries that they plainly do not know about. You managed to hit the nail upon the top and
    also defined out the whole thing without having side-effects , people could take a signal.

    Will likely be back to get more. Thanks

    Feel free to visit my web site … curing sciatica

  8. coping with eczema on 05/10/2021 at 10:04 am

    Only wanna admit that this is invaluable, Thanks for taking your time
    to write this.

    Also visit my web blog; coping with eczema

  9. care personal skin on 05/10/2021 at 10:11 am

    After going over a handful of the blog articles on your web page, I honestly like your technique of blogging.

    I book marked it to my bookmark website list and will be checking back soon. Please visit my website as well and tell me how you feel.

    Also visit my blog post … care personal skin

  10. Minna on 05/10/2021 at 10:14 am

    Hey! Do you use Twitter? I’d like to follow you if that would be okay.

    I’m undoubtedly enjoying your blog and look forward to new updates.

    my web blog; eating diet – Minna

  11. how to drive your man crazy sexually on 05/10/2021 at 10:30 am

    There is obviously a lot how to drive your man crazy sexually know about this.

    I suppose you made some nice points in features also.

  12. eczema remedies on 05/10/2021 at 10:35 am

    For hottest news you have to visit world wide web and on web I found this website
    as a best web page for most up-to-date updates.

    Feel free to surf to my blog post :: eczema remedies

  13. Jacquie on 05/10/2021 at 10:35 am

    Thanks for all of your effort on this blog. My mother loves carrying out
    investigations and it’s simple how to lose weight (Jacquie) grasp why.

    Most of us hear all regarding the compelling form you deliver helpful solutions via the web blog and as well
    as attract response from other ones on this area and our simple
    princess is actually becoming educated a lot of things.
    Take advantage of the remaining portion of the year. You are always
    conducting a superb job.

  14. Bart on 05/10/2021 at 10:37 am

    Hi, There’s no doubt that your web site could be having web browser compatibility issues.
    Whenever I take a look at your website in Safari, it looks fine but when opening in Internet Explorer, it
    has some overlapping issues. I merely wanted to give you a quick heads up!
    Aside from that, excellent site!

  15. Newton on 05/10/2021 at 10:40 am

    This is a topic that’s near to my heart… Many thanks!
    Exactly where are your contact details though?

  16. high fat on 05/10/2021 at 10:56 am

    Next time I read a blog, I hope that it won’t disappoint me just as much
    as this one. I mean, I know it was my choice to read through, but I genuinely believed you
    would have something interesting to say. All I hear is a bunch of moaning about something that you can fix if you weren’t too
    busy seeking attention.

    Have a look at my webpage; high fat

  17. diets that work on 05/10/2021 at 10:57 am

    you’re in reality a good webmaster. The website
    loading pace is amazing. It seems diets that work you are
    doing any unique trick. In addition, The contents are
    masterpiece. you have performed a wonderful job on this subject!

  18. https://www.mhes.tyc.edu.tw on 05/10/2021 at 11:03 am

    There is obviously a lot to realize about this.

    I think you made certain good points in features also.

    Also visit my website; cannabis license (https://www.mhes.tyc.edu.tw)

  19. sex tips on 05/10/2021 at 11:22 am

    Good info and straight to the point. I don’t know if this is actually the
    best place to ask but do you folks have any ideea where to employ some professional writers?
    Thanks in advance 🙂

    Also visit my web-site – sex tips

  20. good healthy eating on 05/10/2021 at 11:24 am

    It’s remarkable for me to have a web page, which is useful in favor of
    my experience. thanks admin

    Feel free to surf to my page; good healthy eating

  21. facial skin care routine on 05/10/2021 at 11:24 am

    Some genuinely interesting information, well written and broadly speaking user
    friendly.

    Here is my blog post: facial skin care routine

  22. kannikar.com on 05/10/2021 at 11:33 am

    I have been browsing online more than three hours today, yet I never found any interesting article like yours.
    It’s pretty worth enough for me. In my opinion, if all web owners and bloggers made good content as you did, the net
    will be a lot more useful than ever before.

    my web blog :: fast weight loss (kannikar.com)

  23. Appreciating the persistence you put into your blog and in depth information you offer.
    It’s great to come across a blog every once in a while that isn’t the same outdated rehashed information. Wonderful read!
    I’ve saved your site and I’m including your RSS
    feeds to my Google account.

    Visit my blog post; low carbohydrate (http://www.aniene.net/modules.php?name=Your_Account&op=userinfo&username=Robbie18V)

  24. 023wst.com on 05/10/2021 at 11:44 am

    F*ckin’ amazing issues here. I am very glad to look your post.

    Thanks so much and i am having a look ahead to contact you.

    Will you please drop me a e-mail?

    Also visit my web-site; ketogenic diet (023wst.com)

  25. Coy on 05/10/2021 at 11:52 am

    Definitely believe that which you stated. Your favorite justification appeared to be on the net the simplest
    thing to be aware of. I say to you, I definitely
    get annoyed while people think about worries that they just don’t 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 probably be back
    to get more. Thanks

  26. Jonelle on 05/10/2021 at 11:57 am

    Thank you for another fantastic post. Where else could anyone get that type of
    information in such an ideal manner of writing? I have a presentation subsequent
    week, and I’m on the search for such information.

    Also visit my webpage how to burn fat (Jonelle)

  27. ketogenic diet for bodybuilding on 05/10/2021 at 12:00 pm

    I am regular reader, how are you everybody? This article posted
    at this web site is in fact fastidious.

    my page: ketogenic diet for bodybuilding

  28. 100% pure skin care on 05/10/2021 at 12:14 pm

    Some truly nice and useful information on this web
    site, also I conceive the design contains wonderful features.

    Also visit my web blog … 100% pure skin care

  29. seo tips on 05/10/2021 at 12:35 pm

    always i used to read smaller articles or reviews which as well clear their motive, and
    that is also happening with this article which I am reading at this place.

    Stop by my web page … seo tips

  30. www.fotosombra.com.br on 05/10/2021 at 12:51 pm

    Great blog you have got here.. It?s hard to find quality writing
    like yours nowadays. I truly appreciate people like you!
    Take care!!

    Review my web blog … best sexual tips; http://www.fotosombra.com.br,

  31. Benito on 05/10/2021 at 1:07 pm

    I’ve been exploring for a little bit for any high-quality articles or blog
    posts in this sort of area . Exploring in Yahoo I finally stumbled upon this website.
    Reading this info So i am happy to exhibit that I’ve an incredibly just right uncanny feeling I came upon exactly what I needed.

    I so much definitely will make sure to don?t put out of your mind this site and give it
    a look regularly.

  32. quanfff.com on 05/10/2021 at 1:22 pm

    These are genuinely impressive ideas in concerning blogging.

    You have touched some good points here. Any way keep
    up wrinting.

    Here is my web-site: better sex tonight (quanfff.com)

  33. Ann on 05/10/2021 at 1:48 pm

    Greate post. Keep posting such kind of information on your site.
    Im really impressed by your site.
    Hello there, You’ve done a fantastic job. I will certainly
    digg it and in my view recommend to my friends. I am sure they’ll be benefited
    from this website.

  34. 163.30.42.16 on 05/10/2021 at 1:48 pm

    Hi there! Quick question that’s completely off
    topic. Do you know how to make your site mobile friendly?
    My website looks weird when browsing from my iphone. I’m trying to find a theme
    or plugin that might be able to correct this problem.
    If you have any suggestions, please share. Appreciate it!

    Also visit my site; amazing weight loss (163.30.42.16)

  35. Cyril on 05/10/2021 at 2:24 pm

    Hello would you mind sharing which blog platform you’re using?
    I’m going to start my own blog soon but I’m having a difficult time selecting between BlogEngine/Wordpress/B2evolution and Drupal.

    The reason I ask is because your design seems different then most blogs and I’m looking for something unique.
    P.S Apologies for getting off-topic but I had to ask!

  36. Delphia on 05/10/2021 at 3:44 pm

    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.

  37. better marriage sex on 05/10/2021 at 3:57 pm

    Hey there just wanted to give you a brief heads up and let you
    know a few of the images aren’t loading properly. I’m not sure
    why but I think its a linking issue. I’ve tried it in two different browsers and both show
    the same outcome.

    my page better marriage sex

  38. Tommie on 05/10/2021 at 4:04 pm

    I truly love your blog.. Pleasant colors & theme. Did you build this
    site yourself? Please reply back as I’m attempting to
    create my own website and would like to learn where you got this from or exactly what the theme
    is named. Kudos!

  39. Ruby on 05/10/2021 at 4:11 pm

    I love what you guys are usually up too. This kind of clever work and coverage!

    Keep up the fantastic works guys I’ve incorporated
    you guys to my personal blogroll.

  40. healthy skin care on 05/10/2021 at 4:12 pm

    Thank you, I’ve just been looking for info approximately this subject for a long time
    and yours is the greatest I’ve discovered till now. But, what concerning the conclusion? Are
    you positive about the source?

    my web-site … healthy skin care

  41. Priscilla on 05/10/2021 at 4:38 pm

    I loved as much as you’ll receive carried out right here.
    The sketch is attractive, your authored subject matter stylish.
    nonetheless, you command get got an impatience over that you wish
    be delivering the following. unwell unquestionably come further formerly again as exactly the same nearly
    very often inside case you shield this hike.

  42. http://www.a913.vip on 05/10/2021 at 4:44 pm

    I really love your blog.. Excellent colors & theme.
    Did you build this website yourself? Please reply back as I’m trying to create my very own website and would like to find out where you got this from or exactly what the theme is named.
    Cheers!

    my website :: nerve pressure (http://www.a913.vip)

  43. Sven on 05/10/2021 at 4:50 pm

    There’s definately a lot to find out about this subject.
    I really like all the points you’ve made.

  44. drug abuse statistics on 05/10/2021 at 5:11 pm

    Hello Dear, are you really visiting this web page regularly, if so afterward you will definitely
    get nice knowledge.

    Also visit my web blog :: drug abuse statistics

  45. Kathy on 05/10/2021 at 5:12 pm

    What a stuff of un-ambiguity and preserveness of valuable familiarity about
    unexpected emotions.

  46. ckd diet on 05/10/2021 at 5:22 pm

    Hi, after reading this awesome paragraph i am also glad to share my knowledge here
    with mates.

    Also visit my blog post ckd diet

  47. Earnest on 05/10/2021 at 5:32 pm

    Do you mind if I quote a couple of your articles
    as long as I provide credit and sources back to your site?
    My blog site is in the exact same niche as yours and my visitors would certainly benefit from
    a lot of the information you provide here. Please let me
    know if this okay with you. Thank you!

  48. Rory on 05/10/2021 at 5:42 pm

    What i do not understood is in fact how you are not really much more
    neatly-appreciated than you might be right now.
    You’re so intelligent. You already know thus significantly when it comes to this subject,
    made me personally believe it from so many various angles.
    Its like women and men aren’t involved until it is something to accomplish with Lady gaga!
    Your individual stuffs nice. At all times deal with it up!

  49. Rosalinda on 05/10/2021 at 6:06 pm

    Unquestionably believe that which you said. Your favorite justification seemed to be on the net the easiest thing to be aware of.
    I say to you, I certainly get annoyed while people think about
    worries that they plainly do not know about.
    You managed to hit the nail upon the top and defined out
    the whole thing without having side effect , people can take a signal.

    Will probably be back to get more. Thanks

  50. Aurelio on 05/10/2021 at 6:43 pm

    Have you ever considered publishing an e-book or guest authoring
    on other sites? I have a blog based upon on the
    same information you discuss and would love to have you share some stories/information. I know my subscribers would value your work.
    If you are even remotely interested, feel free to shoot me an e mail.

  51. Pamala on 05/10/2021 at 8:58 pm

    This article presents clear idea designed for the new users of blogging, that really how to do running a
    blog.

  52. Latasha on 05/10/2021 at 10:42 pm

    I always used to study article in news papers but now as I am a user of net
    thus from now I am using net for posts, thanks to web.

  53. Denise on 05/10/2021 at 11:25 pm

    Hi, i think that i saw you visited my website so i came to “return the favor”.I’m attempting
    to find things to enhance my website!I suppose its ok to use some of your ideas!!

  54. Conrad on 05/10/2021 at 11:51 pm

    Keep on writing, great job!

  55. Sibyl on 06/10/2021 at 2:02 am

    Quality articles or reviews is the main to be a focus for
    the visitors to pay a quick visit the website, that’s what this website is
    providing.

  56. Https://knifepointhorror.wiki/ on 06/10/2021 at 3:31 am

    Terrific post however I was wanting to know if you could write a litte more on this subject?
    I’d be very grateful if you could elaborate a little bit further.
    Thank you!

  57. Lea on 06/10/2021 at 4:21 am

    In fact when someone doesn’t know then its up to other viewers that
    they will help, so here it happens.

  58. agen judi slot on 06/10/2021 at 4:22 am

    What a information of un-ambiguity and preserveness of precious familiarity concerning unpredicted
    feelings.

  59. Rashad on 06/10/2021 at 5:51 am

    I have been exploring for a little bit for any high-quality articles or
    blog posts in this sort of space . Exploring in Yahoo I
    eventually stumbled upon this website. Studying this info So i am happy to express that I have a very excellent uncanny
    feeling I came upon just what I needed. I most unquestionably will make sure to
    do not forget this website and provides it a look on a
    continuing basis.

  60. Ellen on 06/10/2021 at 6:14 am

    Greetings! I’ve been reading your site for some time now
    and finally got the bravery to go ahead and give you a shout out from Dallas Texas!
    Just wanted to mention keep up the excellent job!

Leave a Comment