Non-resolution of acidosis and ketosis
Acidosis not improving | Ketosis not improving |
Insufficient insulin or drug error? | Check infusion lines |
Inadequate resuscitation? | Insufficient insulin prescribed? |
Underlying sepsis? | Incorrect preparation of insulin infusion? |
Hyperchloraemic acidosis? (related to excessive use of chloride containing fluids) | Inadequate fluid input? |
Recreational or prescription drugs? | Underlying sepsis? |
Cerebral oedema
Fig 16: Cerebral oedema is a potentially life-threatening complication of DKA in young people |
Cerebral oedema has high mortality and morbidity[11-12,58]
Late signs are associated with extremely poor prognosis.
Senior staff must be informed immediately if suspected.
Discuss with PICU consultant & arrange urgent transfer.
Immediate management of cerebral oedema involves the following[22]:
Warning signs[22,25] | Risk factors[25] |
Headache | Younger age[63] |
Change in neurological status (reduction in GCS, change in restlessness, irritability or incontinence) | Initial presentation of T1DM[9,63] |
Focal neurological signs (i.e. cranial nerve palsies) | Longer duration of symptoms[64] |
Relative bradycardia & hypertension (Cushing’s reflex) | Greater volumes of fluid within the first 4 hours of treatment[33,65-66] |
Reduced oxygen saturations | Insulin infusion started within the first hour of treatment[33] |
Abnormal posturing | Use of bicarbonate during treatment[11,67] |
Oculomotor palsies, pupillary inequality or dilatation | Greater hypocapnia at presentation[11,65,68] |
Late signs: convulsions, coma, papilloedema, respiratory arrest | Increased serum nitrogen at presentation[11,68] |
More severe acidosis at presentation[33,66,69] |
Accurate documentation
Fig 17: Accurate documentation is required in the management of all critically ill patientsAs with all critically ill patients ensure notes are: |
As with all critically ill patients ensure notes are: