A 13-year-old boy presenting with type 1 diabetes mellitus develops an acute illness with vomiting. Blood glucose is 380 mg/dL. Blood gas: pH 7.18, HCO3 10 mEq/L. Serum sodium is 130 mEq/L. During DKA fluid resuscitation, the most dreaded and potentially fatal complication to monitor for is:

• A Hypoglycemia from excess insulin
• B Hyperchloremic acidosis from normal saline administration
• C Hypokalemia causing cardiac arrhythmia
• D Cerebral edema ✓

Explanation

Cerebral edema is the most feared complication of DKA treatment in children, occurring in 0.5–1% of pediatric DKA but causing 25% of DKA-related deaths. It typically occurs 4–12 hours after starting treatment, manifesting as headache, deteriorating consciousness, Cushing's triad, or sudden neurological deterioration. Risk factors include younger age, new-onset DKA, higher initial BUN, and excessive fluid administration. The exact mechanism involves rapid osmotic shifts. Treatment is immediate hypertonic saline (3% NaCl) or mannitol. While hypokalemia and hypoglycemia are real risks, cerebral edema is the leading cause of death and disability in pediatric DKA.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.