Peds DKA with AMS - Treat Now CT Later

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Just treat...scan later
Cerebral edema is a feared complication of DKA, especially in children.  In this retrospective single-center study of almost 700 kids with DKA, about 14% had altered mental status.  Those with AMS were younger, sicker, and had worse looking numbers.  Not all these got a head CT.  Of those who did, a minority were abnormal.  Not all got hyperosmolar therapy, but of those who did, CT did not seem to influence the decision to treat or not.  And CT may have delayed treatment up to 2 hours for some children.  Here is my take.  Cerebral edema in DKA is a clinical diagnosis.  If they have DKA and become altered, assume it's cerebral edema and empirically treat with hypertonic (our protocol is 3% saline, 3-5 mL/kg over 10 minutes).  Imaging decisions can be made after you treat.

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Head CT does not help you decide whether or not to use hyperosmolar therapy in pediatric DKA with cerebral edema and may delay initiation of treatment.  Treat first; scan later.


Abstract

Pediatr Crit Care Med. 2017 Jan 19. doi: 10.1097/PCC.0000000000001027. [Epub ahead of print]

Suspected Cerebral Edema in Diabetic Ketoacidosis: Is There Still a Role for Head CT in Treatment Decisions?

Soto-Rivera CL1, Asaro LAAgus MSDeCourcey DD.

Author information:

11Division of Medicine Critical Care, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA. 2Division of Endocrinology, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA. 3Department of Cardiology, Boston Children's Hospital, Boston, MA.

Abstract

OBJECTIVES:

Neurologic deterioration associated with cerebral edema in diabetic ketoacidosis is typically sudden in onset, progresses rapidly, and requires emergent treatment. The utility of brain imaging by head CT in decisions to treat for cerebral edema has not been previously studied. The objective of this study was to describe the characteristics of pediatric patients with diabetic ketoacidosis who develop altered mental status and evaluate the role of head CT in this cohort.

DESIGN:

Retrospective analysis of clinical, biochemical, and radiologic data.

SETTING:

Tertiary care children's hospital (2004-2010).

PATIENTS:

Six hundred eighty-six admissions of patients (< 26 yr) with diabetic ketoacidosis.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Altered mental status was documented during 96 of 686 diabetic ketoacidosis admissions (14%). Compared with alert patients, those with altered mental status were younger (median, 12.0 vs 13.1 yr; p = 0.007) and more acidotic (pH, 7.04 vs 7.19; p < 0.001), with higher serum osmolality (328 vs 315 mOsm/kg; p < 0.001) and longer hospital length of stay (4.5 vs 3 d; p = 0.002). Head CT was performed during 60 of 96 diabetic ketoacidosis admissions with altered mental status (63%), 16 (27%) of which had abnormal results. Hyperosmolar therapy for cerebral edema was given during 23 of the 60 admissions (38%), during which 12 (52%) had normal head CT results, eight of these 12 (67%) after cerebral edema treatment and four (33%) before. Of the 11 admissions with abnormal head CT results that received hyperosmolar therapy, four head CT scan (36%) occurred after hyperosmolar treatment and seven (64%) before. For the 11 admissions with head CT before cerebral edema treatment, there was a median 2-hour delay between head CT and hyperosmolar therapy.

CONCLUSIONS:

In this single-center retrospective study, there was no evidence that decisions about treatment of patients with diabetic ketoacidosis and suspected cerebral edema were enhanced by head CT, and head CT may have led to a significant delay in hyperosmolar therapy.

PMID: 28107262 [PubMed - as supplied by publisher]