Hot Seat Case Denouement #129: 8 yo with hyperglycemia

Posted on: April 12, 2019, by :

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

Case: 8 yo girl with DKA becoming progressively more altered during ED stay with concern for cerebral edema

Here’s how you answered the questions:

Discussion:

Despite DKA being “bread and butter” Peds EM, there is enough about this case to have us all on the edge of our seats. The majority of fellows and attendings quickly picked up on her altered mental status and requested a Head CT from the get go.

As the patient becomes progressively more altered, the question then becomes how bold do you feel transporting the patient versus starting treatment for cerebral edema? Dr. Lindgren cited Muir et al. (Diabetes Care 2004), which developed diagnostic protocol for diagnosing cerebral edema (with 92% sensitivity and 96% specificity). The below table puts forth the diagnostic, major, and minor criteria (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).

Diagnostic criteria:
– Abnormal motor or verbal response to pain
– Decorticate or decerebrate posture
– Cranial nerve palsy (especially III, IV, and VI)
– Abnormal neurogenic respiratory pattern (e.g., grunting, tachypnea, Cheyne-Stokes respiration, apneusis)
Major criteria:
– Altered mentation/fluctuating level of consciousness
– Sustained heart rate deceleration (decline more than 20 bpm) not attributable to improved intravascular volume or sleep state
– Age inappropriate incontinence
Minor criteria:
– Vomiting
– Headache
– Lethargy or being not easily aroused from sleep
– Diastolic blood pressure >90 mmHg
– Age <5 years

Since this patient has three of the minor criteria (headache, vomiting, lethargy), most argued for immediate treatment of her cerebral edema and forgoing Head CT.

Dr. Siems also cited literature to support the lack of utility of Head CT in cases such as this. Soto-Rivera et al (Peds Crit Care 2017) performed a retrospective chart review of 686 patients admitted with DKA, 96 of whom were altered. Sixty patients of those who were altered received a Head CT. There was no evidence that Head CT changed management of these patients, and in fact, led to a delay in hyperosmolar therapy.

Next, we discussed which hyperosmolar fluid to use in the setting of AMS. If you had a different patient who was not so hypernatremic, 3% HTS may be better to use in DKA as it is a volume expander. With a corrected sodium greater than 160mEq/L, 3% HTS may be less effective in decreasing ICP. Mannitol would lead to increased diuresis in an already intravascularly depleted patient. In addition, with a BG >1400, mannitol seemed to be futile as the patient would likely be maximally diuresed. There did not seem to be a correct answer in this case as our patient’s initial corrected sodium was 159. Ultimately, Endo/ICU/PEM colleagues agreed that the best choice would be the one most readily available that the provider is most comfortable with.

Lastly, discussion finished with which maintenance fluid to use when your patient is very hypernatremic. Her corrected sodium was 173 after 3% HTS administration. Everyone agreed not to give hypotonic fluids given the risk for correcting her sodium to quickly would lead to worsening cerebral edema.

Denouement

Patient was admitted to the PICU for management of DKA and hypernatremia. She was changed to 1/2NS fluids at 1.5xmIVF and did well. She remained in the hospital for an extra day after correction of her acidosis to correct her hypernatremia and safely discharged home.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

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