Endocrine Abstracts

DKA guidelines aim to reduce risk of cerebral oedema. We present the outcomes of three young females with severe DKA with reduced conscious level at diagnosis that required deviation from these guidelines.

A. 12-year-old, pH 6.88 with DKA and sepsis. Received 20 ml/kg initial fluid bolus. CT head scan was normal. Hypotension required further fluid boluses, inotropes and an increase in fluids to 65% above the rate on DKA protocol. Although slow to wake after stopping sedation (4 days), she sustained no obvious neurological deficit. MRI head was normal.

B. 13-year-old, pH 6.72 with DKA, acute renal failure and candida sepsis. Received 20 ml/kg initial fluid bolus. Initial CT head scan was normal. Peritoneal dialysis was required days 7–11 as she was anuric. She was slow to wake from sedation. MRI brain showed severe diffuse ischaemic changes. She was discharged neurologically normal aside from right foot drop.

C. 14-year-old, pH 6.6 with DKA, peri-arrest, profound shock, candida sepsis and renal failure. Received 120 ml/kg fluid boluses and inotropes to gain cardiovascular stability. Initial CT head scan was normal. Poor perfusion led to necrotic skin lesions and caecal perforation. Haemodialysis was required. MRI head scan showed multifocal acute haemorrhagic striatal and leukoencephalopathic lesions. She is now making good progress with apparently normal cognitive function.

These cases demonstrate the challenges involved in treating those with severe DKA. In two of the cases, patients received large fluid volumes to restore circulating volume however did not develop cerebral oedema. The cases of severe renal failure were challenging as fluid and glucose management from a renal point of view can differ from diabetes management plans.