Risk factors |
Severe acidosis at presentation |
Substantially elevated BUN at presentation |
Severe hypocapnia |
Young child (<5 years) and/or new onset of diabetes – These are not independent risk factors but are markers for more severe DKA because they are associated with delayed diagnosis of DKA |
Diagnosis of cerebral injury* |
Minor criteria (moderately suspicious findings) |
Headache – Although headache is frequently present at diagnosis, worsening or recurrence of headache during treatment is suspicious for cerebral injury |
Vomiting – Vomiting is suspicious if it develops or recurs during treatment |
Irritability, lethargy, or not easily aroused from sleep – These features are suspicious particularly if they occur or worsen after initiation of therapy |
Elevated BP (eg, diastolic BP >90 mmHg). |
Major criteria (very suspicious findings) |
Abnormal or deteriorating mental status after initiation of therapy, agitated behavior, or fluctuating level of consciousness |
Incontinence inappropriate for age |
Inappropriate slowing of heart rate – eg, decline more than 20 beats per minute that is not attributable to improved intravascular volume or sleep state |
Diagnostic criteria (signs of significant brain injury, increased intracranial pressure, or brain herniation) |
Abnormal motor or verbal response to pain |
Decorticate or decerebrate posture |
Abnormal pupillary response or other CN palsy¶ |
Abnormal neurogenic respiratory pattern – eg, grunting, tachypnea, Cheyne-Stokes respiration, apnea |
Treatment |
Indications* |
Child with DKA and:
|
Interventions |
Give mannitol, 0.5 to 1 g/kg intravenously over 15 minutes; the mannitol dose may be repeated in 30 minutes, if there is no initial responseΔ |
Adjust fluid administration as indicated to maintain normal BP and optimize cerebral perfusion Avoid hypotension that might compromise cerebral perfusion pressure Neurosurgery consultation regarding further management, including possible invasive monitoring of intracranial pressure in selected cases |
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