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 – pCO – pO 2 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 fluid 1 Concerns about hyperchloraemic acidosis 2 Ringers Lactate 3 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% Saline 4 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 hrs Lower fluid boluses associated with lower incidence of brain herniation 6 0% patients receiving 50ml/kg in 1 st 4 hrs

Predictors of Cerebral Oedema No sodium increase as glucose falls Development of hyponatraemia Initial hypernatraemia Low initial pCO 2 7 High initial blood urea 7

Management of Cerebral Edema High incidence of subclinical cerebral edema prior to fluid therapy 8 Prevent 20% Mannitol ml/kg IV over 20 mins or 3% Saline 5ml/kg over 30 mins 1 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 ([Glucose] – 5.5) Corr Na + = Na ([Glucose] – 5.5) - alternative Na + requirement: = total body water x (desired Na + – serum Na + ) Total H 2 O 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 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): Rutledge J and Couch R. Initial Fluid Management of Diabetic Ketoacidosis in Children. American Journal of Emergency Medicine. Oct 2000; 18(6): Glaser ND et al. Risk Factors for Cerebral Edema in Children with Diabetic Ketoacidosis. NEJM. Jan 2001; 344(4): Krane E, Rockoff M, Wallman J, Wolfsdorf J. Subclinical brain swelling in children during treatment of diabetic ketoacidosis. N Engl J Med 1985;312: