Pneumomediastinum and subcutaneous emphysema in diabetic ketoacidosis

Alternative management of diabetic ketoacidosis in a Brazilian pediatric emergency department

DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.

Pneumomediastinum, pneumopericardium, and epidural pneumatosis in DKA

Pneumomediastinum (PM) is an uncommon condition characterized by the presence of air in the mediastinum. It is associated with alveolar rupture that allows air to traverse along the bronchovascular bundle into the mediastinum. A review of the world medical literature identified 50 additional cases of PM and pneumopericardium (PC) associated with diabetic ketoacidosis (DKA). We report the occurrence of PM, PC, as well as epidural pneumatosis occurring simultaneously in a patient with DKA. Epidural pneumatosis in association with this metabolic derangement has not been previously described.

Spontaneous pneumomediastinum and diabetic ketoacidosis

Spontaneous pneumomediastinum is a rare complication of diabetic ketoacidosis. We report two patients with this complication who presented to a Sydney hospital within one week. Although both patients were young backpackers, staying at the same hostel, we believe this was coincidental.