1331

Abstract

Introduction: A 16 year-old female presented to an outside hospital after being found unresponsive at home. The day prior to presentation the patient was treated for tonsillitis with ceftriaxone. Because of depressed mental status, she was intubated and a head CT was obtained and read as normal. She was severely acidotic with an initial arterial pH of 6.7 and a bicarbonate of 5 mmol/L. A measured glucose was 482 mg/dL. During transport to our ED, the patient developed shock resulting in a total of 5L fluid resuscitation (115 ml/kg). In the ED dopamine and norepinephrine were initiated for fluid-refractory shock. A repeat head CT was again normal. She was started on an insulin drip and isotonic fluid at 2 times maintenance for DKA. In the PICU the patient required ongoing fluid resuscitation (30 ml/kg) and titration of vasopressors. The patient's serum osmolality was followed hourly during shock management. Her lowest recorded value was 301 mosmol/kg (normal range 270-310 mosml/kg). The patient's corrected serum sodium was also followed closely, ranging from 145-148 mmol/L. Within 24 hours of admission the patient's acidosis and hyperglycemia resolved. Shock resolved within 34 hours and she weaned from all vasopressor support. She was extubated to room air and had no neurologic deficits on examination. She was transitioned to intermittent insulin and transferred to the Endocrinology service on day #3 of admission. A 3 year-old female presented to our ED after being found unresponsive at home. The day prior to admission she was treated with IM penicillin for Streptococcal pharyngitis. In the ED the patient was intubated for lack of respiratory effort, leading to bradycardic arrest resulting in 2 minutes of CPR and 2 doses of epinephrine. She was in profound shock requiring 60 ml/kg of resuscitative fluid and a dopamine drip. Initial venous pH was 6.84 and bicarbonate was 6 mmol/L. Her first glucose was 1450 mg/dL. She was started on an insulin drip and isotonic fluid at 2 times maintenance for DKA. A head CT obtained was normal. In the PICU the patient had persistence of shock requiring further fluid resuscitation and the addition of an epinephrine drip. Stress-dose hydrocortisone was added for catecholamine-refractory shock. During the first 24 hours of admission the patient demonstrated dramatic urine output and glucosuria, prompting urine replacements in order to maintain her intravascular volume. She received a total of 280 ml/kg of resuscitative fluid. During active resuscitation, calculated serum osmolality ranged from 330-356 mosmol/kg, corrected sodium from 138-167 mmol/L. A head CT was repeated on day #2 and was again negative. By 48 hours of admission the patient's shock, acidosis, and hyperglycemia resolved. She weaned off vasopressors, hydrocortisone was discontinued, and urine replacements were stopped. She was extubated on day #5 of admission. Neurologically the patient could follow commands, but was noted to have mildly increased tone in her upper and lower extremities. She was transferred to the Endocrinology service on day #8 of admission. At 6 months post-discharge she was reported to be back to her neurologic baseline with normal tone. Cerebral edema remains the major life-threatening complication of children with DKA. Though the mechanism for cerebral edema remains unclear, one theory is grounded in rapid osmotic shifts and supports the use of judicious fluid administration. In circumstances of both DKA and persistent shock, conservative fluid administration may be inadequate to maintain perfusion. In such extreme cases, no established guideline exists. This report describes 2 patients with new onset DKA and shock who had consistently normal head CTs and mild, reversible neurological deficits despite large resuscitative fluid volumes. Further study is warranted before change in standard resuscitative practice can be advocated for in these fragile patients.