A 12-year-old known type 1 diabetic presents in DKA: blood glucose 480 mg/dL, pH 7.08, bicarbonate 6 mEq/L, serum sodium 128 mEq/L. After 1 hour of normal saline resuscitation (10 mL/kg), his neurological status suddenly deteriorates and he becomes unresponsive. CT head reveals diffuse cerebral edema. Which factor is MOST strongly associated with this complication in pediatric DKA?
- A Rapid correction of blood glucose below 250 mg/dL
- B Administration of sodium bicarbonate for pH <7.0
- C Initial high BUN and low arterial pCO2 at presentation ✓
- D Use of hypotonic fluid for deficit replacement
Explanation
Cerebral edema is the most feared complication of pediatric DKA, occurring in 0.5–1% of episodes but accounting for 57–87% of DKA mortality. Independent risk factors identified in large prospective studies (PECARN DKA FLUID, Glaser 2001) include higher BUN (marker of severe dehydration), lower arterial pCO2 (marker of severe acidosis), and failure of serum sodium to rise with treatment. Rapid glucose correction per se is not independently causative; it is the failure of sodium to correct appropriately during treatment that matters. Bicarbonate use is associated with increased cerebral edema risk but is not the strongest predictor. Hypotonic fluids increase risk but are not a stronger independent predictor than high BUN or low pCO2 at presentation.
Reference: Ghai Essential Pediatrics, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.