Managing Cerebral Oedema in Children with Paediatric Diabetic Ketoacidosis: A Policy Review and Recommendations

This assignment discusses the policy from a major hospital in Australia which has adopted the framework for managing Cerebral Oedema in children due to Paediatric Diabetic Ketoacidosis. It also provides recommendations for future policy.

NUR5926 Assessment 2
Contemporary

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................3
Outlining the policy and context -...................................................................................................3
Recommendations –.........................................................................................................................5
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................11

INTRODUCTION
Paediatric diabetic ketoacidosis (DKA) has been determined as the common presentation of
type 1 diabetes mellitus and type 2 diabetes mellitus among children and adolescents.
Mechanism of DKA is associated with the lack of insulin in the body. The decreased rate of
insulin along with the corresponding elevation of the glucose leads to increase in the release of
glucose in liver. The treatment of paediatric diabetic ketoacidosis is concerned with the
administration of the intravenous fluids along with insulin (Abbas & et.al. (2018). However, in
this context during treatment close clinical monitoring for the signs of Cerebral Oedema is
required. Furthermore, effective interventions are often required. There has been clear link
established in the paediatric diabetic ketoacidosis and cerebral Oedema. It has been stated as
potential complication in the paediatric diabetic ketoacidosis. Cerebral Oedema which often
stated as swelling in the brain is one of the most serious complication of paediatric diabetic
ketoacidosis. Studies have found that, lack of blood flaw in brain during DKA cause the
complication. (Cerebral Oedema). In addition to this, keen monitoring and interventions are
required.
In this assignment, discussion in regards to policy from a major hospital in Australia which
have adopted the framework in context of managing Cerebral Oedema in children due to
paediatric diabetic ketoacidosis will be done. In addition, the appropriate reference will be made
only to the intra emergency monitoring and intervention of Cerebral Oedema. The discussion in
regards of the policy has been taken in consideration as effective monitoring is required in
relation of solving the complexities that may be created due to Cerebral Oedema. Furthermore,
intervention needs to be stated in well-defined manner that can be used at the time of emergency.
Within considering this, critical situation can be managed. Moreover, recommendation in context
of future policy will be proposed in the assignment.
Outlining the policy and context -
As per the views of Eisenhut, (2018) in order to manage the complex situation (Cerebral
Oedema) proper medication and therapy has to be given to the children. In case, the patient is on
a surgical unit then the immediate actions need to be taken are associated with the reducing the
fluid rate by 1/3, giving mannitol 0.5-1g/kg IV over the 20 minutes. Glackin & et.al. (2020)
Elucidates that, risk of cerebral oedema is higher. Additional risk of the diagnosis during the

treatment includes higher acidosis and very elevated BUN at the presentation. Using bicarbonate
for the treatment of the acidosis, the greater volume of the fluid has to be given under the first 4
hours of the treatment. Also, administration of the short acting insulin under the 1 hour of fluid
treatment is performed. Considering this information, there is lack of consistency in the hospital
services. This clearly presents the mandatory need in context of quality improvement and the
policy revision practice. The framework that has been adopted in the Hospital have stated that,
close monitoring and interventions are required. However, appropriate information in this
regards have not been mentioned. In addition to this Araya & Menon, (2020) said that Diagnostic
criteria involves the abnormal motor or the verbal response to the pain, cranial nerve palsy,
decorticate or decerebrate posture and abnormal neurogenic respiratory pattern.
As stated by Nehring, Tadi & Tenny, (2019) the major criteria aligned with the altered
mental status, sustained heart rate deceleration, fluctuation level in the consciousness and the
minor criteria entitled with the vomiting, lethargy, headache, diastolic BP >90 mm Hg in the age
<5 years of children. The data that has been collected depicting the wide difference in the
framework adopted by hospital in context of managing cerebral oedema. The information that
has been reviewed in the policy of hospital was just limited to the minor criteria of the diagnosis.
Thus, there is a strong need in terms of revising policy.
As per the views of Agarwal, (2019) Cerebral Oedema is associated with the range of
different cause that involves Brain Tumor, Infection, Traumatic brain injury and so on. Often, the
diagnosis of the cerebral oedema is highly challenging as service provider must perform the
physical exam of the head and neck, CT scan and MRI of the head, blood test need to be
performed and a neurological exam as well. However, the collected data is clearly depicting the
mandatory task that has to be performed in order to monitor the risk of Cerebral oedema in
patient so the timely actions can be taken. The policy framework of the hospital needs to be
revised in this context as the emergency diagnosis criteria for cerebral oedema has not been
mentioned. In accordance with the major treatment or therapy that needs to be follow for treating
the cerebral oedema are medication, surgery, Hypothermia and Osmotherapy.
In context of medication studies have shown that, medical professionals used drugs in
order to reduce the swelling and blood clots. The major example of the drug is warfarin that
helps in thinning the blood and decreases the chance of blood clot. In some cases, service
provider often recommends Aspirin. However, current guidelines do not provide this advice for

most of the patient as in may increases the chance of bleeding. In this context, policy of hospital
has not provided specific information that states that the policy needs to be revised as
pharmacotherapy management is important along with the proper information of the varied
effects of drugs. Surgery in many cases are necessary as cerebral oedema develops the fluid
around brain and increases the pressure in the brain that is known as intracranial pressure (ICP).
Thus, when the pressure becomes excessive in such case surgery becomes highly important. It
involves removing the part of skull and repairing the damage.
As stated by Tasker & et.al. (2020) Hypothermia is the form of therapy that is associated
with lowering the body temperature that helps in reducing the swelling in the brain. This therapy
helps in providing instant relief to the children who is facing cerebral oedema. Another therapy is
Osmotherapy that involves using of medication that helps in removing water from brain and
stimulates blood flow in the brain and reduces the intracranial pressure (ICP). The collected cues
and facts are aligned with the therapies, medication and surgery that is required in context of
managing the complex situation (cerebral oedema). However, the therapies are the instant actions
that can be taken in the emergency period. The policy of the hospital has not mentioned about
these therapies (Hypothermia and Osmotherapy) that can provide instant relief to the children
who are facing Cerebral oedema. Often, proper medication in this context have not been
followed. However, cerebral oedema has been considered as the serious threat. In accordance
with the hospital policy the treatment that has been mentioned is, giving hypertonic IV fluid
without delaying and if signs persist then it should be repeat and the CT scan should not be
performed before the definitive treatment. General action includes, attending ABC, halve IV
fluid rate, maintaining the insulin at 0.05units/kg/hr and placing the child in the head up position
if it is safe.
Thus, current policy of the hospital in this context only recommends this. However,
cerebral oedema leads to ICP that is that is life threatening situation that requires more effective
attention and detail description in regards to monitoring the Cerebral oedema and providing
intervention in this context.
Recommendations –
There are certain recommendations which are being addressed and are identified in the manner to
prevent the children from having Cerebral Oedema. These recommendations are based on the

situation and the condition that how worst is the health condition of children and what treatment
is provided to them which is based on the monitoring and intervention. If the situation of
children gets worst due to Diabetic Ketoacidosis, then proper care and treatment is provided to
them.
Monitoring – Monitoring is the best manner in which the aspects of how effectively the disease
should be managed. For the treatment of DKA successful clinical and biochemical monitoring is
done if the conditions get worst. There should be timely adjustment of the insulin dose,
electrolyte status. Oxygen, antibiotics and cardiac monitoring is required to analyse the situation
of children having Cerebral Oedema Bassell, Swenson, Serrano-Gonzalez & et.al., (2018).
Constant monitoring and assessment of hydration is absolutely essential which helps in analysing
that the inner body system being affected due to Diabetic Ketoacidosis. Meticulous monitoring
of the child is also an important way of monitoring and analysing that how effectively and in
appropriate manner the Diabetic Ketoacidosis in the children can be stopped. Neurological
observations for the warning symptoms and signs of cerebral oedema should be measured on an
hourly basis. Children having Diabetic Ketoacidosis should be monitored frequently and closely.
Blood glucose should be evaluated every one to two hours until the child is stable.
The blood urea nitrogen, potassium and bicarbonate levels should be monitored every
two to six hours depending on the severity of DKA. There is very careful monitoring of the
potassium levels of the children having Diabetic Ketoacidosis. It is very important that the
monitoring is done in an appropriate manner which helps in maintaining the balances of levels
within the body Abdulkader, (2020). Antibiotics for suspected or identified DKA is being
analysed and this affects the body of the child when they are having such disease. The hospital in
Australia should change the current practice as it is not helping the children to cure from the
disease as they are suffering from Diabetic Ketoacidosis. There should be provisions and
providence of the administration of intravenous fluids and insulin. If the monitoring is not done
properly then there will be serious complications which the children might face and this will
result in having cerebral oedema which is fatal complication of Paediatric Diabetic Ketoacidosis.
The hospital in Australia should follow all the essential rules and regulations and along with this
policy changes are the best manner in which the hospitals should provide proper monitoring at
large scale Ravikumar & Bansal, (2021). Children should be provided hospitalization for closed
clinical and laboratory monitoring until the Cerebral Oedema resolves. Close neurologic

monitoring should be done so that the children are able to cure from the disease and its worst
complications. The hospitals of Australia should provide the intensive care units for the children
who are adversely suffering and are facing the severe health problem which is DKA. The
adversities arise when there is no proper monitoring and the children face major problem due to
Diabetic Ketoacidosis.
Further, the nursing staff should be trained and monitored and written guidelines should
be provided and framed in such manner that the hospitals in Australia are following all the
important guidelines which are related to Diabetic Ketoacidosis. The electrocardiogram
monitoring should be done in an appropriate manner for the value of children which is creating
major concerns of how the health of children is affected due to Diabetic Ketoacidosis and they
are in need of proper treatment Nor, Fong & et.al., (2018). Ketonuria should be used as a
measure of improvement. Bedside fingerstick sample monitor for beta – hydroxybutyrate will
avoid this problem. Therefore, there are aspects as to how effectively and in appropriate manner
the monitoring of the Diabetic Ketoacidosis in the children should be taken care of. This helps in
directing the inner sugar levels by knowing that how they are managed and are appropriately
providing the concerns of cure and treatment so that there are no adversities which are faced such
as cerebral oedema. The hospital in Australia change its practice such that the children are able
to recover from the problem.
Based on the research findings, it has been found that children <16 years are diagnosed
with T1D in Western Australia during 2000 - 2019 Leinert, (2019). Moderate-severe DKA at
diagnosis was defined as serum pH < 7.2 or bicarbonate<10 mmol/L with hyperglycemia and
ketosis. Therefore, it is recommended that proper monitoring and care should be provided to the
children who are suffering from the Cerebral Oedema. Proper monitoring in hospital of Australia
will help in getting cure from the disease which will provide the aspects as to how the adversities
are to be stopped which can cause cerebral oedema in the body of children.
Interventions – It has been recommended that there are proper interventions which should be
followed for providing care and treatment from the Diabetic Ketoacidosis due to which the
children are suffering. The initial intervention which should be taken place for children suffering
from Diabetic Ketoacidosis in hospital of Australia concerns the aspect of restoration of extra
cellular volume of fluid through the administration of intravenous of a normal saline solution

having 0.9% sodium chloride Medley, Miteff & et.al., (2019). Potassium (K) must be replaced
early and sufficiently. Appropriate intervention was also less frequent in the litigated cases. The
intervention includes reduction in the rate of fluid administration and elevation of the head of the
bed. Although there has been early intervention with the treatment of mannitol having the
improved outcome because there has been increased recognition of the problem. Due to the
major complication which the children are suffering from is the development of Cerebral
Oedema. An initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to
supply maintenance and replace 5%–10% dehydration.
Monitoring the vitals should be done of the children having the Diabetic Ketoacidosis.
This intervention when adopted by the hospital of Australia will help in analysing and
determining the aspects of how effectively and in appropriate manner there are aspects which are
helping the children to solve their health problem which is having Diabetic Ketoacidosis.
Checking of the renal functioning should be done so that the children are treated and are provide
care in not reaching to the adversities of having Cerebral Oedema Patwardhan, Gorton & et.al.,
(2018). The mental status of the children should also be considered and taken into prevalence
such that they feel motivated and relive their life by the changing practices adopted by the
hospital of Australia. Checking of the renal function should be measured and identified within
children such that there are no adverse effects which the children might be facing. The hospital
should maintain insulin at 0.05 units/kg/hr. For the early signs which have been identified call
for the ICU consultant. Attending to ABC should be considered by the hospital. In emergency
conditions, place the child in head up condition (30 degrees). Halving of the IV fluid rate is the
best measure which the children should take and care about.
Further, the hospital should make the child go through the CT scan before the definitive
treatment takes place. In the severe situation where the child is facing the persistent coma of
signs of cerebral herniation, there are advanced resuscitation which includes hyperventilation and
maintenance of cerebral perfusion pressure which is highly specialized. Hypertonic IV fluid
should be given to the patient without any delay. For the later signs when identified or diagnosed
in the patient having Cerebral Oedema then call a paediatric code blue. Moreover, the best
available team as easy and quick as possible should be called which consists of the ICU, ED,
Paediatrics should be recruited as soon as possible. Further, the hospital should also follow the
therapies of hyperthermia and Isotherapy Rajani, Pearce & et.al., (2018). These two type of

therapies will help the patient in gaining better health and will not suffer from Cerebral Oedema
in adverse conditions. Both the therapies should be framed in an appropriate manner as to how
effectively the care and treatment is provided to the patients.
Therefore, these are some of the interventions which the hospital should follow at large
scale so that proper treatment and cure is being provided to them in an appropriate manner.
These interventions are helping to address the aspects of how the older practice should be
changed and new intervention should be taken into the framework at large scale. There are
aspects as to how effectively and in appropriate manner the interventions are necessary and are
framed so that the patients and children are not suffering in the adverse conditions of having
Cerebral Oedema Avanali, Gopalakrishnan & et.al., (2019).
Moreover, the recommendations are framed to analyse and to create value as to how
effectively the care should be provided to the patients and children who are suffering from the
adverse effects of Diabetic Ketoacidosis and this has caused them Cerebral Oedema. This is the
major aspect as to how effectively and in appropriate manner there is significance of how
effectively the care of the patients is be taken and what interventions the hospital should follow
in curing the patients.
CONCLUSION
Certain limitation has been witnessed in the hospital of Australia in context of emergency
management of Cerebral oedema. The excessive pressure has been created on the brain due to
this it requires the instant relief for children as they could not bear excessive pressure therefore,
effective services that helps in emergency period are required in this context. This has been
considered as the serious threat that can create the serious brain issues in children. However,
policy of hospital in this context has shown ineffectiveness. Thus, a clear need can be witnessed
in regards to revising the policy. So, proper management in this regards can be done. To
overcome the limitation, immediate response (therapies) and effective monitoring is required on
regular basis. This enable nurse to perform holistic care approach towards the patient and the
results would be effective.
Current practices of hospital have certain limitation that is concerned with the ineffective
quality services in context of ED. Therefore, proposing a change in the policy is required that
helps in overcoming the certain barrier that are aligned with the current policy of hospital.

Cerebral oedema can create serious threat for children that may impact their brain. Therefore,
proper steps of monitoring that are highly required in order to managing the complexities needs
to revised in the policy. Along with this, proper approaches of intervention need to be developed
in this context. The recommendations that has been given in the report are clearly depicting the
effective ways of monitoring and intervention approaches that helps in making policy more
effective. Thus, final conclusion that has been deprived is that policy of the hospital needs to be
revised so effective quality services to the children in context of cerebral oedema can be assured.

REFERENCES
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