Ver el código de «Cerebral edema in DKA»

==Background==
*1% of patients with DKA<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>
*Almost all affected patients are <20yr <ref>Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, et al. Frequency of subclinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. Apr 2006;7(2):75-80.</ref>
*Associated with initial bicarb level; not rate of glucose drop 
**Children presenting with higher blood urea nitrogen levels and more severe acidosis are at higher risk

===Pathophysiology===
*Thought to be due to cerebral hypoperfusion and less likely osmotic shifts with rapid infusion of IVF's <ref> Kuppermann, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018;378:2275-87</ref>

===Risk Factors===
*Age <5yo
*Severe hyperosmolality
*Failure of sodium to rise with therapy
*Severe [[acidosis]]
*Previous episodes of DKA
*Late presentation for medical evaluation
*Overaggressive fluid resuscitation is ''NOT'' a risk factor

==Clinical Features==
*Begins 6-12hr after onset of therapy or may begin before initiation of treatment or up to 48h afterward
**Many appear to be improving from their DKA before deteriorating from cerebral edema
*Premonitory symptoms:
**[[Headache]] 
**[[urinary incontinence|Incontinence]] 
**[[Seizure]]
**Acute [[mental status changes]]
**Signs of [[herniation Syndromes|herniation]]

==Differential Diagnosis==
{{Hyperglycemia DDX}}

==Evaluation==
*Stat [[CT brain|head CT]] (non-contrast)
*Capillary glucose measurement to rule out [[hypoglycemia]] as the cause of altered mental status

==Management<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>==
*Head of bed at 30 degrees
*[[Mannitol]] 0.5-1gm/kg IV bolus over 20 minutes
**Give a repeat does if there is an inadequate response
**If 2 doses of mannitol are ineffective, consider 3% saline 10mL/kg over 30min
*Fluid restriction - decrease the IVF infusion rate by 30%
**Treat noncardiogenic [[pulmonary edema]], if present
*Consult neurosurgery (and PICU/ICU as appropriate)

==Disposition==
*Admit PICU/ICU

==See Also==
*[[Diabetes mellitus (main)]]
*[[DKA]]
*[[DKA (Peds)]]

==References==
<references/>

[[Category:Endocrinology]]
[[Category:Neurology]]
[[Category:Critical Care]]