Treating cerebral edema in diabetic ketoacidosis: caveats in extrapolating from traumatic brain injury*

A 5-year-old with new-onset diabetes presenting with ketoacidosis, acute pancreatitis, and renal failure

A 5-year-old girl presented to the emergency room with altered mental status secondary to severe diabetic ketoacidosis due to new-onset GAD65 antibody positive, type 1 diabetes mellitus. On hospital day 0, she developed anuria, shock, and hypertriglyceridemia-associated acute pancreatitis. Following intravenous insulin therapy, the patient’s ketoacidosis improved. Her other complications persisted for several days and improved only with significant fluid resuscitation and supportive interventions, including intubation, thoracostomy, and vasopressors. This case underscores the importance of recognizing the early warning signs of diabetic ketoacidosis and reviews how to appropriately manage its associated life-threatening complications.

Application of bench studies at the bedside to improve outcomes in the management of severe diabetic ketoacidosis in children-a narrative review

OBJECTIVE

In this review, we address a few key issues and the challenges faced in the management of severe diabetic ketoacidosis (DKA) in children, highlighting the existing standard of care, supported by evidence and bench studies.

BACKGROUND

The classic triad of DKA namely hyperglycemia, metabolic acidosis and ketonemia warrants immediate attention with fluids and insulin. Correction of dehydration in DKA is of utmost priority and the calculation of fluid volume and choice of fluid have remained a matter of debate. Insulin therapy, to halt the ketone production, in DKA has undergone wide variations in dose and preparation since its discovery. Although the mortality due to severe DKA has remarkably decreased, complications like cerebral edema and acute kidney injury (AKI) continue to haunt the intensivists and endocrinologists on a few occasions.

METHODS

We have selected a few important questions in the management of severe DKA in children, addressing the challenges, reviewing the studies, guidelines and bedside practices with evidence in this narrative review.

CONCLUSIONS

The focus of management should be to understand and normalise the deranged physiology rather than trying to get normal laboratory reports. This needs careful understanding of the pathogenesis and deriving conclusion from bench studies. With newer studies and evidence, guidelines are revised every few years. There is a trend towards more conservative therapy, with continuous and advanced monitoring. Switching to subcutaneous insulin and oral hydration is done as early as possible with clinical monitoring and resolution of DKA. Management of severe DKA in children can vary from simple fluid titration and insulin infusion in mild cases to a scenario with multiorgan dysfunction requiring intensive monitoring and advanced organ support. Individualisation of therapy to suit the needs with the available evidence and expertise is extremely essential.