Case Presentation

Andreas Crede
EM Registrar
 Case
• 12 year old male
• 1/12 fatigue
• Severe LOW
• 3/7 increasing SOB
• 1/7 confusion + lethargy
 Case
• Med Hx: Nil
• Chronic Medication: Nil
• Allergies: Nil known

• Multiple GP visits: fatigue due to puberty

 Case
• Clinically:
– Emaciated
– P 140 BP 70/40 RR 45 Temp 37.6°C
– Glucose: 36 mmol/l
– Acidotic breathing, shocked
– CNS – drowsy, but rousable, orientated to person,
not place or time
– Other systems essentially normal
 Case
• Urine Ketones +
• UEC 129/ 5,2/ 9.3/ 108
• ABG
– pH 7.05
– pCO2 1.8
– pO2 18
– Bicarb 5.2
– BE – 20
 Case
• Problems
• New Type I DM
• DKA
• Hypovolaemic Shock
• Hyponatraemia
• Cerebral Oedema
 Management
• First bolus: 10ml/kg N/Saline – remained hypotensive
• Second bolus 10ml/kg N/Saline: still hypotensive, but ↑
confusion
• Concern about worsening cerebral oedema
• Fluid boluses stopped, commenced on fluid rehydration 0.45%
Saline
• Admitted to ICU
• CT Brain: cerebral oedema
• Worsened over next 48 hrs, but eventually made complete
recovery
 Case
• Type of fluid?
• Volume for resuscitation?
• Management of cerebral oedema in DKA?
• Predictors of cerebral oedema in DKA?
 Type of Fluid
• Normal (0.9%) Saline
• Generally recommended fluid1
• Concerns about hyperchloraemic acidosis2
• Ringers Lactate3
• More hypotonic → increased risk cerebral oedema
• Lactate potentially metabolised to glucose
• Non-metabolised lactate can ↓ level of consciousness
• Contains potassium
 Type of Fluid
• No evidence to support other crystalloids/
colloids for resuscitation
• Very little evidence overall for different fluids
• Best evidence for 0.9% Saline4
• If not available, isotonic fluid
• Consider 0.45% saline for rehydration if
hypernatraemic
 Volume for Resuscitation
• ≤ 10ml/kg boluses repeat to max 3 doses
(30ml/kg)1,5
• Fluid bolus not required if not shocked
• Fluid deficit replacement over 24-48 hrs
• Lower fluid boluses associated with lower
incidence of brain herniation6
• 0% patients receiving <25ml/kg in 1st 4 hrs vs 20%
receiving >50ml/kg in 1st 4 hrs
 Predictors of Cerebral Oedema
• No sodium increase as glucose falls
• Development of hyponatraemia
• Initial hypernatraemia
• Low initial pCO27
• High initial blood urea7
 Management of Cerebral Edema
• High incidence of subclinical cerebral edema prior to
fluid therapy8
• Prevent
• 20% Mannitol 2.5-5.0 ml/kg IV over 20 mins or 3%
Saline 5ml/kg over 30 mins1
• Change replacement fluid to 0.45% Saline
• Slow IV fluids – replace over 72 hrs
• Head up position
 Useful Formulas
• Na+ for hyperglycaemia correction:
• Corr Na+ = Na+ +0.4([Glucose] – 5.5)
• Corr Na+ = Na+ +0.3([Glucose] – 5.5) - alternative
• Na+ requirement:
• = total body water x (desired Na+ – serum Na+)
• Total H2O deficit:
• = total body water x (1- [desired Na+/ actual Na+])
• Total body water
• Children = 0.6 x wt
• Women = 0.5 x wt
• Men = 0.6 x wt
• Elderly Female = 0.45 x wt
• Elderly Male = 0.5 x wt
 References
1. BSPED
2. www.ccm.lsuhsc-s.edu/Clinical/Disease/DKA.htm
3. www.anaesthetist.com
4. Harris GD, Fiordalisi I. Physiologic management of diabetic ketoacidemia. A 5-year prospective
pediatric experience in 231 episodes. Arch Pediatr Adolesc Med. Oct 1994;148(10):1046-52.
5.Rutledge J and Couch R. Initial Fluid Management of Diabetic Ketoacidosis in Children.
American Journal of Emergency Medicine. Oct 2000; 18(6):658-60
6. www.med.umich.edu
7. Glaser ND et al. Risk Factors for Cerebral Edema in Children with Diabetic Ketoacidosis. NEJM.
Jan 2001; 344(4):264-9
8. Krane E, Rockoff M, Wallman J, Wolfsdorf J. Subclinical brain
swelling in children during treatment of diabetic ketoacidosis. N Engl J Med
1985;312:1147-51.