Cerebral edema in DKA: First do no harm!

Article Outline

• Copyright

The development of cerebral edema during the acute treatment of diabetic ketoacidosis (DKA) is a rare but potentially devastating complication. Over the past few years, The Journal has published a number of studies that have attempted to elucidate the cause and prevention of this life-threatening disturbance.

In the current issue, our knowledge about cerebral edema in DKA is expanded upon with a careful observational study by Hoorn et al. These workers undertook a retrospective examination of data from cohorts of children treated at their center for DKA who either did or did not develop cerebral edema. The major difference noted between the two groups was an early drop in effective plasma osmolality in the cerebral edema group. The group that did not develop this fall in osmolality had either a smaller drop in plasma glucose, a slight rise in plasma sodium, or both. The cerebral edema group tended to receive more fluid early in treatment.

These observations are put into a very helpful perspective in an accompanying editorial by Friedman. Although it is likely that there are a host of causes of cerebral edema in DKA—indeed there may be vascular abnormalities at presentation that are predisposing—these publications suggest that the initial fluid therapy may play a role as well. This observation is somewhat in conflict with current consensus statements on the topic. From a practical standpoint, the thrust of these articles suggests that avoiding precipitous drops in plasma glucose, and avoiding overly aggressive rehydration, particularly with less-than-isotonic fluid, are important strategies in the management of DKA.