July 15, 2007
Dear Paw Paw:
Recently an 8 year old girl presented in DKA. She was not known to be a diabetic. Her serum glucose was 540. The rest of her labs were: Na=119, K=3.1, CO2=12 and a BUN of 35. Her venous blood gases showed a pH of 7.2 and pCO2 of 31. She was tachycardic, tachypneic and nauseated. Naturally I wanted to get her glucose down fast, and correct her acidosis. So I gave her an ampule of bicarbonate IV, started NS IV at 1 liter/hour, gave an insulin bolus of 0.1unit/kg, and then started an insulin drip at 0.1units/kg/hour.
Within an hour or so, she developed lethargy and headache, and then became hard to arouse. Shortly thereafter she began posturing and became unstable. She was admitted to the ICU. The Pediatric Intensivist said she developed cerebral edema.
Although I know I did my part as quickly as I could, I feel bad that her family waited too long before they brought her to the ED. Now if she survives at all, she will be neurologically impaired for the rest of her life. What should I say to them to relieve them of the guilt they must feel?
Dr. Charles Wezz, Frogbottom, Georgia
Dear Dr. Cheese Whiz:
You get the King Pyrrhus Award for 2007. Yep you won the battle, but unfortunately lost the war. Using what few functioning neurons you have, you may remember that Pyrrhus was a cousin of Alexander the Great and an outstanding military leader. He was a strong opponent of Rome. In the battle of Asculum in 279 BC he lost irreplaceable losses in his ‘victory’ over the Romans. Hence the term Pyrrhic victory, but I digress.
More to the point, cerebral edema (CE) can be seen in DKA, especially in children. OK it only happens about 1% of the time. But the mortality is reported as anywhere between 40 – 90 %! It should be anticipated and at the first signs, it must be treated aggressively. The thoughts about why this happens are more complex and numerous than JFK Conspiracy Theories.
Factors that are suspected to predispose to CE are: use of bicarbonate, low pCO2, preexisting hyponatremia, high BUN, overaggressive fluid resuscitation, use of insulin bolus, and lowering of glucose too quickly.
This girl had hyponatremia, even after corrected for the elevated glucose. The formula is: corrected Na = measured Na + ([1.6 x (glucose – 100)] ÷ 100). Her corrected Na is 126. He BUN was high, her pCO2 was low. She was definitely at risk. The bicarbonate and bolus insulin are now “no - no’s”.
You do get a few “ata boys” for using a venous blood gas to check her acid base balance. Remember you are doing this for acid base reasons not to check her oxygenation. The pCO2 on the venous side is not significantly different than on the arterial side and a VBG is a heck of a lot easier to obtain than an ABG, especially on a kid.
Unfortunately it sounds like her brain has been turned into the neurologic equivalent of a bowl of Lime Jell-O. And despite what Bill Cosby says, Lime Jell-O is not acceptable to anyone anymore.
Often the initial symptoms are subtle: irritablitity, lethargy, head ache. You have to know about it to think of it. You have to think of it to recognize it. And you have to recognize it to treat it. Get it?
If you start to see any signs it is imperative to stop the insulin, decrease the fluids and treat as you would any other episode of cerebral edema. Early treatment with Mannitol is advised. Some recommend taping a dose to the head of the bed and giving as soon as you suspect CE. Early aggressive treatment is the only chance for an acceptable outcome.
.
This young girl’s family did nothing wrong and they have nothing for which they should feel guilty. You on the other hand are another story.
Now go in peace my son. Your penance is to recite “I Will Not Be an Idiot” three times while genuflecting in front of the statue of Sir William Osler, and promise to never sin again.
By the way you may find these articles of interest:
1. Risk Factors for Cerebral Edema in Children with DKA – NEJM, January 25, 2001; Volume 344, Number 4, Pages: 264-269.
http://content.nejm.org/cgi/content/full/344/4/264
2. Diabetic Ketoacidosis and Cerebral Edema by Elliot Krane, MD
http://pedsccm.org/FILE-CABINET/Metab/DKA-CEdema.html
Then again, maybe you should do your own damn Google search!
Paw Paw
Dear Paw Paw:
Recently an 8 year old girl presented in DKA. She was not known to be a diabetic. Her serum glucose was 540. The rest of her labs were: Na=119, K=3.1, CO2=12 and a BUN of 35. Her venous blood gases showed a pH of 7.2 and pCO2 of 31. She was tachycardic, tachypneic and nauseated. Naturally I wanted to get her glucose down fast, and correct her acidosis. So I gave her an ampule of bicarbonate IV, started NS IV at 1 liter/hour, gave an insulin bolus of 0.1unit/kg, and then started an insulin drip at 0.1units/kg/hour.
Within an hour or so, she developed lethargy and headache, and then became hard to arouse. Shortly thereafter she began posturing and became unstable. She was admitted to the ICU. The Pediatric Intensivist said she developed cerebral edema.
Although I know I did my part as quickly as I could, I feel bad that her family waited too long before they brought her to the ED. Now if she survives at all, she will be neurologically impaired for the rest of her life. What should I say to them to relieve them of the guilt they must feel?
Dr. Charles Wezz, Frogbottom, Georgia
Dear Dr. Cheese Whiz:
You get the King Pyrrhus Award for 2007. Yep you won the battle, but unfortunately lost the war. Using what few functioning neurons you have, you may remember that Pyrrhus was a cousin of Alexander the Great and an outstanding military leader. He was a strong opponent of Rome. In the battle of Asculum in 279 BC he lost irreplaceable losses in his ‘victory’ over the Romans. Hence the term Pyrrhic victory, but I digress.
More to the point, cerebral edema (CE) can be seen in DKA, especially in children. OK it only happens about 1% of the time. But the mortality is reported as anywhere between 40 – 90 %! It should be anticipated and at the first signs, it must be treated aggressively. The thoughts about why this happens are more complex and numerous than JFK Conspiracy Theories.
Factors that are suspected to predispose to CE are: use of bicarbonate, low pCO2, preexisting hyponatremia, high BUN, overaggressive fluid resuscitation, use of insulin bolus, and lowering of glucose too quickly.
This girl had hyponatremia, even after corrected for the elevated glucose. The formula is: corrected Na = measured Na + ([1.6 x (glucose – 100)] ÷ 100). Her corrected Na is 126. He BUN was high, her pCO2 was low. She was definitely at risk. The bicarbonate and bolus insulin are now “no - no’s”.
You do get a few “ata boys” for using a venous blood gas to check her acid base balance. Remember you are doing this for acid base reasons not to check her oxygenation. The pCO2 on the venous side is not significantly different than on the arterial side and a VBG is a heck of a lot easier to obtain than an ABG, especially on a kid.
Unfortunately it sounds like her brain has been turned into the neurologic equivalent of a bowl of Lime Jell-O. And despite what Bill Cosby says, Lime Jell-O is not acceptable to anyone anymore.
Often the initial symptoms are subtle: irritablitity, lethargy, head ache. You have to know about it to think of it. You have to think of it to recognize it. And you have to recognize it to treat it. Get it?
If you start to see any signs it is imperative to stop the insulin, decrease the fluids and treat as you would any other episode of cerebral edema. Early treatment with Mannitol is advised. Some recommend taping a dose to the head of the bed and giving as soon as you suspect CE. Early aggressive treatment is the only chance for an acceptable outcome.
.
This young girl’s family did nothing wrong and they have nothing for which they should feel guilty. You on the other hand are another story.
Now go in peace my son. Your penance is to recite “I Will Not Be an Idiot” three times while genuflecting in front of the statue of Sir William Osler, and promise to never sin again.
By the way you may find these articles of interest:
1. Risk Factors for Cerebral Edema in Children with DKA – NEJM, January 25, 2001; Volume 344, Number 4, Pages: 264-269.
http://content.nejm.org/cgi/content/full/344/4/264
2. Diabetic Ketoacidosis and Cerebral Edema by Elliot Krane, MD
http://pedsccm.org/FILE-CABINET/Metab/DKA-CEdema.html
Then again, maybe you should do your own damn Google search!
Paw Paw
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