Factors predicting cerebral edema in young children with diabetic ketoacidosis and new onset type I diabetes

Abstract

We have attempted to identify any characteristics which could be used to predict the development of cerebral edema in four children under 5 years of age with new onset insulin-dependent diabetes mellitus and diabetic ketoacidosis. We retrospectively analysed and compared the concentration of serum sodium (corrected for serum glucose value) and effective serum osmolality of these 4 children with values of 10 age-matched controls with new onset insulin-dependent diabetes mellitus who did not develop cerebral edema during treatment of diabetic ketoacidosis. The initial serum sodium values of the two groups were not statistically different. Patients who developed cerebral edema had lower initial serum glucose values and effective serum osmolality. During treatment, patients who developed cerebral edema had consistently lower mean serum sodium and osmolality than controls at each 4-h interval after the first 4 h of therapy. Serum sodium and osmolality declined progressively after the initiation of therapy in cerebral edema patients, while remaining stable in controls. These data suggest that children who develop cerebral edema during treatment for diabetic ketoacidosis initially may have a relatively normal serum osmolality and subsequently develop progressive hyponatremia and/or a trend of declining serum sodium before developing cerebral edema.

The UK case–control study of cerebral oedema complicating diabetic ketoacidosis in children

“…Rate of fluid administration [9] and use of relatively dilute fluids in rehydration protocols [6,7,11] have often been implicated in the aetiology of cerebral oedema complicating DKA [17]. Our data provide some support for this hypothesis in that the use of large volumes of fluid over the first 3 to 4 h of rehydration was significant in our models.…”

“…Many previous studies have been more selective, with the possibility of introducing bias [9][10][11]. Although identification of cases and controls was carried out prospectively, examination of case records was retrospective, and some of the cases and controls reported were invalid, because either the case did not have cerebral oedema or the control did not have DKA.…”

Care of Children and Adolescents With Type 1 Diabetes

“…Cerebral edema is an important cause of DKA-associated deaths in childhood and for 20% of all deaths in children with diabetes Ͻ20 years of age (107). While cerebral edema has been reported in individuals in the fourth decade of life, it is most common in patients Ͻ15 years old who are severely dehydrated (103,108), acidotic, and hyperosmolar. Newly diagnosed patients Ͻ5 years of age seem to be at the greatest risk.…”

Managment of diabetic ketoacidosis in children and adolescents in sub-Saharan Africa: A review

“…Typically, symptomatic cerebral oedema occurs 4-12 hours after the initiation of therapy but cases have also occurred before initiation of therapy (39) and as late as 24-28 hours after the initiation of treatment (40) ( Table 4). Other complications of DKA are summarised below ( Table 4 Signs and symptoms of cerebral oedema (21,31) Risk factors for cerebral oedema Signs and symptoms of cerebral oedema • Age <5 years due to immaturity of auto-…”