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Case Presentation

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

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Case Presentation

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  1. Case Presentation Andreas Crede EM Registrar

  2. Case • 12 year old male • 1/12 fatigue • Severe LOW • 3/7 increasing SOB • 1/7 confusion + lethargy

  3. Case • Med Hx: Nil • Chronic Medication: Nil • Allergies: Nil known • Multiple GP visits: fatigue due to puberty

  4. 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

  5. Case • Urine Ketones + • UEC 129/ 5,2/ 9.3/ 108 • ABG • pH 7.05 • pCO2 1.8 • pO2 18 • Bicarb 5.2 • BE – 20

  6. Case • Problems • New Type I DM • DKA • Hypovolaemic Shock • Hyponatraemia • Cerebral Oedema

  7. 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

  8. Case • Type of fluid? • Volume for resuscitation? • Management of cerebral oedema in DKA? • Predictors of cerebral oedema in DKA?

  9. 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

  10. 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

  11. 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

  12. Predictors of Cerebral Oedema • No sodium increase as glucose falls • Development of hyponatraemia • Initial hypernatraemia • Low initial pCO27 • High initial blood urea7

  13. 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

  14. 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

  15. 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 CouchR. 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.

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