Cerebral edema in pediatric diabetic ketoacidosis

Diabetic ketoacidosis is the most common cause of morbidity and mortality in children with type I diabetes mellitus. The main cause of pediatric death is cerebral edema responsible for intracranial hypertension. This cerebral edema appears in approximately 1% of ketoacidosis, mostly in the first 24 hours of management. Even if the pathophysiology remains unclear, some risk factors have been identified, principally due to the preexistent conditions, but also to iatrogenic events. Improvement in epidemiologic, pathophysiologic and clinical knowledge has resulted in great progress in the management of ketoacidosis, thus reducing morbidity and mortality in the most recent series. Intracranial hypertension can be responsible for major brain impairment; however, most of the time, cerebral edema is subclinical. This highlights the importance of a systematic research for detecting primary signs of cerebral edema in all patients presenting ketoacidosis in order to improve their management. We will review the principal aspects of management of pediatric ketoacidosis regarding diagnosis (clinical and radiological with the development of transcranial doppler) and treatments. The best guaranty to obtain a significant reduction in morbidity and mortality depends on the early recognition of type I diabetes mellitus, before ketoacidosis, which could be considered as a public health objective, which has already been reached in several countries.