Once you've made the presumptive diagnosis of cerebral edema in Pediatric DKA (refer to part 1), here's what's next:
DO NOT GET A HEAD CT - this will only waste your time, recall that most children with DKA have subclinical cerebral edema
Reduce the fluid rate by at least half
Start mannitol at 0.25-1g/kg IV over 20 minutes (may repeat in 2 hours)
OR (not and)3% saline at 5-10mL/kg over 30 minutes (slightly less used and supported)
If you intubate, DO NOT HYPERVENTILATE. A pCO2 < 22 mmHg is associated with poorer outcomes, presumably secondary to ischemia from reduced bloodflow...
Mortality from cerebral edema in DKA is 20-25%, and 15-35% of survivors have permanent disability.
The best strategy is to do your best to avoid cerebral edema in the first place, but if you do recognize it, this is a clinical diagnosis, and you should not delay treatment for radiographic studies.
References
Dunger, DB, Sperling, MA, Acerini, CL, et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 2004; 113:e133.
Dunger, DB, Sperling, MA, Acerini, CL, et al. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child 2004; 89:188.
Marcin, JP, Glaser, N, Barnett, P, et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr 2002; 141:793.
