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A 4-year-old with history of type 1 diabetes mellitus presents with 1-2 days of nausea, vomiting, decreased appetite, shortness of breath, and a few hours of declining responsiveness. Vital signs on arrival are: temp 37.6 C, HR 160, RR 38, BP 120/70, pulse ox 98% on room air. A point-of-care glucose reads “HIGH” and a point-of-care iStat shows a pH of 6.97 with a bicarb of 10 and potassium of 4.3. The patient is obtunded and responding only to pain. A rapid fluid bolus is started and an insulin drip is being prepared.
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May 12, 2026 at 5:32 pm
D) Give mannitol 0.5 to 1 gm/kg IV
This patient with severe diabetic ketoacidosis (DKA) is showing signs of a critical complication: cerebral edema, which can lead to morbidity or mortality. Risk factors include severe acidosis on presentation, elevated BUN on presentation, and young age with new-onset DKA (usually because the new-onset status meant a delayed diagnosis). It used to be thought that rapid fluid boluses increased risk, but the PECARN FLUID trial showed no difference in outcomes between those receiving rapid and slow fluid boluses nor between ½ normal and normal saline use. Treatment of suspected significant cerebral edema should be empiric, before obtaining CT. Mannitol is typically given initially; hypertonic saline may also be used. Aggressive hyperventilation and bicarbonate administration are not recommended and actually may increase risk of poor outcome.