Introduction: Diabetic Ketoacidosis (DKA) is a known risk factor for ischaemic and haemorrhagic stroke in children and young people. Cerebral oedema may predispose to ischaemic or haemorrhagic brain injury, however not all cases of stroke are associated with cerebral oedema. This case illustrates severe complications of DKA including ischaemic stroke and cardiac arrest, and raises questions about fluid management in severe DKA.
Case report: We describe the case of an 8-year-old girl presenting as a new diagnosis of type 1 diabetes in severe DKA. Findings at presentation included a blood glucose level of 35 mmol/l, blood ketones 3.9 mmol/l, pH 6.75, bicarbonate 1.6 mmol/l and Base Excess −33.7. She had a fluctuating conscious level with a GCS between 9 and 13. Initial management included a 10 ml/kg fluid bolus of normal saline, followed by maintenance fluid as per BSPED 2015 guidelines. She was subsequently admitted to the paediatric intensive care unit and commenced on intravenous insulin at 0.05 units/kg/hr. A dopamine infusion was commenced for inotropic support in view of concerns regarding hypotension, tachycardia and poor peripheral perfusion. At 15 h after the initial presentation, left arm and leg weakness was noted, prompting an urgent CT head. This revealed a right thalamic infarct, with no evidence of cerebral oedema. Shortly after returning from the radiology department she had an asystolic cardiac arrest requiring 2 min of CPR and 1 dose of IV adrenaline. Insulin requirements increased up to a maximum of 0.24 units/kg/hour following these events, despite resolution in ketosis. Subsequent results include a normal coagulation screen and an MRI brain consistent with previous findings, showed an established right thalamic infarct.
Conclusions: Cerebral Ischaemic stroke is a known, but rare complication of DKA. Proposed mechanisms of elevated thrombosis risk in DKA include systemic inflammation, disordered coagulation, platelet activation and reduced blood volume and flow. This case describes thalamic stroke and cardiac arrest as severe complications of DKA. It raises questions regarding how to optimally assess fluid status and manage fluid resuscitation and replacement in severe DKA to prevent intracerebral complications.
27 - 29 Nov 2019
British Society for Paediatric Endocrinology and Diabetes