Cerebral injury (cerebral edema) in children with diabetic ketoacidosis: Rapid overview

Risk factors

Severe acidosis at presentation

Substantially elevated BUN at presentation

Severe hypocapnia

Young child (<5 years) and/or new onset of diabetes – These are not independent risk factors but are markers for more severe DKA because they are associated with delayed diagnosis of DKA

Diagnosis of cerebral injury*

Minor criteria (moderately suspicious findings)

Headache – Although headache is frequently present at diagnosis, worsening or recurrence of headache during treatment is suspicious for cerebral injury

Vomiting – Vomiting is suspicious if it develops or recurs during treatment

Irritability, lethargy, or not easily aroused from sleep – These features are suspicious particularly if they occur or worsen after initiation of therapy

Elevated BP (eg, diastolic BP >90 mmHg).

Major criteria (very suspicious findings)

Abnormal or deteriorating mental status after initiation of therapy, agitated behavior, or fluctuating level of consciousness

Incontinence inappropriate for age

Inappropriate slowing of heart rate – eg, decline more than 20 beats per minute that is not attributable to improved intravascular volume or sleep state

Diagnostic criteria (signs of significant brain injury, increased intracranial pressure, or brain herniation)

Abnormal motor or verbal response to pain

Decorticate or decerebrate posture

Abnormal pupillary response or other CN palsy^¶

Abnormal neurogenic respiratory pattern – eg, grunting, tachypnea, Cheyne-Stokes respiration, apnea

Treatment

Indications*

Child with DKA and:

1 diagnostic criterion, or
2 major criteria, or
1 major and 2 minor criteria, or
1 major and 1 minor criterion (if child under 5 years of age)

The decision to treat should be based on signs and symptoms; do not rely on neuroimaging to make or exclude the diagnosis

Interventions

Give mannitol, 0.5 to 1 g/kg intravenously over 15 minutes; the mannitol dose may be repeated in 30 minutes, if there is no initial response^Δ

Adjust fluid administration as indicated to maintain normal BP and optimize cerebral perfusion

Avoid hypotension that might compromise cerebral perfusion pressure

Neurosurgery consultation regarding further management, including possible invasive monitoring of intracranial pressure in selected cases

BUN: blood urea nitrogen; DKA: diabetic ketoacidosis; BP: blood pressure; CN: cranial nerve.
* These clinical criteria and indications are based upon an evidence-based protocol, as outlined in the source below.
¶ Key steps are to evaluate extraocular movements (CN III, IV, and VI) and pupillary dilation and reactivity (CN II and III).
Δ Hypertonic (3%) saline (2.5 to 5 ml/Kg over 10 to 15 minutes) can be used as an alternative to mannitol or if initial treatment with mannitol does not result in improved mental status.

Adapted from: Muir AB, Quisling RG, Yang MCK, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis. Diabetes Care 2004; 27:1541.

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Cerebral injury (cerebral edema) in children with diabetic ketoacidosis: Rapid overview