Hot Seat Case #129: 8 yo with hyperglycemia

Posted on: April 4, 2019, by :

Angelica DesPain, MD, Children’s National Medical Center

with Christina Lindgren, MD, Children’s National Medical Center

8-year-old female with no PMH presents to OSH with vomiting, abdominal pain, and 9 lb. weight loss over 2 weeks. Mom thought she had a viral illness as other kids in the house with similar symptoms but over the last two days she has had more fatigue, increased thirst and urination. At OSH, noted to be Kussmaul breathing with a ketotic smell.

OSH labs:

Na 138, K 5.3, Cl 95, CO2 5.8, Cr 2.0, BUN 39, Ca 10.8, TP 8.4, Alb 4.8, Tbili<0.2, ALK 197, AST 6, ALT 8, Anion Gap 42, Mg 3.5, Phos 7.2, Glucose >1400

VBG 7.0/22/-24, glucose >700

The patient was given a total of 30 ml/kg of normal saline and an insulin drip was started.

Review of Systems

Gen: + Fatigue, denies fever

GI: Abdominal pain, vomiting, no diarrhea

GU: Urinary frequency, no hematuria

Neuro: No confusion, weakness, no seizure, + headache

Endo: Polyuria, polydipsia

No PMH, NKDA, no medications, IUTD

Physical Exam:

T 36.4 HR 163 BP 102/69, RR 28

Gen: Sleepy, will respond to questions though sometimes slow to respond. Very thin

Eye: Pupils are equal, round and reactive to light. EOMI

HEENT: No pharyngeal erythema or exudate. Dry mucous membranes.

CV:  Extremity pulses equal. HR 160s, cap refill 2 sec, cool hands and feet.

Resp: Kussmaul breathing, lungs clear, RR 30

GI: Soft. Nontender. Non distended. Normal bowel sounds. No organomegaly.

Neuro: Waxing and waning, slow to respond to questions but answers are appropriate, will not participate in neuro exam to test strength, withdraws to pain

Upon examination at our ED the patient is noted to appear more altered than previously described. The patient is unable to keep her eyes open and does not recognize her caregivers.

The supervising physician recommends a head CT to see if there is cerebral edema without changing the current management. While awaiting head imaging, the patient is now not responding to questions but withdraws to pain.

You decide to continue the insulin, 1.5x mIVF, and give 3% HTS. As the pharmacist is getting the 3% HTS ready, she states the patient’s corrected sodium is 169. The nurse calls you that CT is ready for the patient.

You give the 3% HTS and the patient becomes more alert and starts to answer questions again. CT head shows no evidence of cerebral edema. One hour later, the sodium is 163 and glucose is 500 (corrected Na 173). You have been running NS containing fluids.

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4 thoughts on “Hot Seat Case #129: 8 yo with hyperglycemia


  1. We would recommend mannitol or hypertonic saline (empiric treatment due to high suspicion for clinical signs of cerebral edema, do not delay by getting head CT). As you may know hypertonic saline had become more widely used but a recent review suggested possible association with increased mortality (attached) but I think that its still not completely clear I personally feel a bit more comfortable with mannitol but I tend to defer to the ED/PICU attending based on their preference.
    -Kim Shimy (Endocrinology)


  2. In my mind the primary question is does this patient meet criteria for treatment? She is at the appropriate time course for developing cerebral edema given that symptoms usually occur 3-12 hours into treatment. She is definitely at high risk given that she has severe acidosis at presentation, she has an elevated BUN and she has new onset diabetes.

    Minor, major and diagnostic criteria for cerebral edema in childhood DKA were established by Muir AB et al in Diabetes Care 2004. The minor criteria include: headache, vomiting, irritability, lethargy or not easily aroused from sleep, or DBP > 90. The Major criteria include: abnormal or deteriorating mental status after initiation of therapy, agitated behavior, or fluctuating level of consciousness; inappropriate slowing of heart rate; or incontinence inappropriate for age. The diagnostic criteria include: abnormal motor or verbal response to pain, decorticate or decerebrate posture, abnormal pupillary response or other cranial nerve (CN) palsy or abnormal neurogenic respiratory pattern – eg, grunting, abnormal tachypnea, Cheyne-Stokes respiration, apnea. Treatment is recommended if a patient has 1 of the diagnostic criteria, 2 major criteria, 1 major and 2 minor or 1 major and 1 minor and is less than 5yo. To this end, she has three of the minor criteria (headache, vomiting, lethargy) and I would argue one of the major criteria given her deteriorating mental status after initiation of therapy . I would therefore say she meets criteria for treatment of cerebral edema in the first question.

    Obtaining head imaging will do nothing to change her management at this point therefore I would defer imaging and treat. Use of mannitol vs. hypertonic saline is a bit complicated. On the one hand she is dry and therefore the osmotic diuresis from mannitol would not be ideal however it would have a quicker effect. On the other hand her corrected sodium on presentation is 158.8. Above a serum sodium concentration of 160mEq/L hypertonic saline fails to effectively decrease ICP. I think I would probably give Mannitol and monitor her uop and BP closely and I would like place a foley to monitor her UOP. I would definitely continue the Insulin and probably keep her fluids at 1.5MIVF initially. Obviously it will be prudent to closely monitor her VS and ensure that we are maintaining adequate BPs to maintain her cerebral perfusion pressure. Some sources suggest decreasing IVF with concern for cerebral edema but she is clearly intravascularly volume depleted as well so this become a delicate balance.

    With the repeat serum Na of 169 I would proceed with Mannitol given that HTS will not longer be effective. Again, this patient seems to be quite ill, a head CT will not change my management acutely and I don’t know that I want her in the CT scanner until her mental status is significantly improved.

    Regarding her fluid management in the final question, it is clear that she is hypovolemic due to both vomiting and ongoing losses for the osmotic diuresis from diabetes. Her losses should improve with her insulin therapy and she already received 30cc/kg NS at the OSH. Given the severity of her hypernatremia, we need to be careful not to correct her Na more than 10-12mEq/L/day or 0.5 mEq/L/hr. I need to do the full calculation (which I will try to do by Thursday 🙂 ) but I would likely put her on ½ NS at 1.5 MIVF.


    1. I have been thinking about this more and I change my last paragraph. NS is going to be hypotonic to her serum sodium regardless and we do not want to correct her Na too fast. NS contains a total of 154mEq/L of sodium. Her primary problem is that the is total body water depleted and as her acidosis improves her hypernatremia will also improve. We need to continue giving water so I think I would give 1.5 NS… likely talk to pharmacy in the interim… and calculate the exact amount she needs to get over the next 12 hours.


  3. Hi All,

    From the ICU viewpoint, there is more and more evidence that imaging is less likely to be worthwhile in DKA since the decision to treat is clinical. Christina has phrased a lot of this very nicely so I won’t go over this point, but a good article to read is this:

    Pediatr Crit Care Med. 2017 Mar;18(3):207-212.
    Suspected Cerebral Edema in Diabetic Ketoacidosis: Is There Still a Role for Head CT in Treatment Decisions?

    This study does have it’s limitations (Single center, retrospective) but highlights a delay to treatment in those patients with cerebral edema. In my opinion, hypertonic is superior to manitol due to less diuresis in patients who are already volume depleted. However, systems issues need to account for how quickly one can get a medication over another.

    I would hold off on hypotonic solutions until the patient is closer to baseline.

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