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Case Presentation Andreas Crede EM Registrar. Case 12 year old male 1/12 fatigue Severe LOW 3/7 increasing SOB 1/7 confusion + lethargy.

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Presentation on theme: "Case Presentation Andreas Crede EM Registrar. Case 12 year old male 1/12 fatigue Severe LOW 3/7 increasing SOB 1/7 confusion + lethargy."— Presentation transcript:

1 Case Presentation Andreas Crede EM Registrar

2 Case 12 year old male 1/12 fatigue Severe LOW 3/7 increasing SOB 1/7 confusion + lethargy

3 Case Med Hx: Nil Chronic Medication: Nil Allergies: Nil known Multiple GP visits: fatigue due to puberty

4 Case Clinically: – Emaciated – P 140 BP 70/40 RR 45 Temp 37.6°C – Glucose: 36 mmol/l – Acidotic breathing, shocked – CNS – drowsy, but rousable, orientated to person, not place or time – Other systems essentially normal

5 Case Urine Ketones + UEC 129/ 5,2/ 9.3/ 108 ABG – pH 7.05 – pCO – pO 2 18 – Bicarb 5.2 – BE – 20

6 Case Problems New Type I DM DKA Hypovolaemic Shock Hyponatraemia Cerebral Oedema

7 Management First bolus: 10ml/kg N/Saline – remained hypotensive Second bolus 10ml/kg N/Saline: still hypotensive, but ↑ confusion Concern about worsening cerebral oedema Fluid boluses stopped, commenced on fluid rehydration 0.45% Saline Admitted to ICU CT Brain: cerebral oedema Worsened over next 48 hrs, but eventually made complete recovery

8 Case Type of fluid? Volume for resuscitation? Management of cerebral oedema in DKA? Predictors of cerebral oedema in DKA?

9 Type of Fluid Normal (0.9%) Saline Generally recommended fluid 1 Concerns about hyperchloraemic acidosis 2 Ringers Lactate 3 More hypotonic → increased risk cerebral oedema Lactate potentially metabolised to glucose Non-metabolised lactate can ↓ level of consciousness Contains potassium

10 Type of Fluid No evidence to support other crystalloids/ colloids for resuscitation Very little evidence overall for different fluids Best evidence for 0.9% Saline 4 If not available, isotonic fluid Consider 0.45% saline for rehydration if hypernatraemic

11 Volume for Resuscitation ≤ 10ml/kg boluses repeat to max 3 doses (30ml/kg) 1,5 Fluid bolus not required if not shocked Fluid deficit replacement over hrs Lower fluid boluses associated with lower incidence of brain herniation 6 0% patients receiving 50ml/kg in 1 st 4 hrs

12 Predictors of Cerebral Oedema No sodium increase as glucose falls Development of hyponatraemia Initial hypernatraemia Low initial pCO 2 7 High initial blood urea 7

13 Management of Cerebral Edema High incidence of subclinical cerebral edema prior to fluid therapy 8 Prevent 20% Mannitol ml/kg IV over 20 mins or 3% Saline 5ml/kg over 30 mins 1 Change replacement fluid to 0.45% Saline Slow IV fluids – replace over 72 hrs Head up position

14 Useful Formulas Na + for hyperglycaemia correction: Corr Na + = Na ([Glucose] – 5.5) Corr Na + = Na ([Glucose] – 5.5) - alternative Na + requirement: = total body water x (desired Na + – serum Na + ) Total H 2 O deficit: = total body water x (1- [desired Na + / actual Na + ]) Total body water Children = 0.6 x wt Women = 0.5 x wt Men = 0.6 x wt Elderly Female = 0.45 x wt Elderly Male = 0.5 x wt

15 References 1. BSPED Harris GD, Fiordalisi I. Physiologic management of diabetic ketoacidemia. A 5-year prospective pediatric experience in 231 episodes. Arch Pediatr Adolesc Med. Oct 1994;148(10): Rutledge J and Couch R. Initial Fluid Management of Diabetic Ketoacidosis in Children. American Journal of Emergency Medicine. Oct 2000; 18(6): Glaser ND et al. Risk Factors for Cerebral Edema in Children with Diabetic Ketoacidosis. NEJM. Jan 2001; 344(4): Krane E, Rockoff M, Wallman J, Wolfsdorf J. Subclinical brain swelling in children during treatment of diabetic ketoacidosis. N Engl J Med 1985;312:


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