Marianna Gisoldi, DNP, APRN, CPNP-AC
Pediatric Critical Care Nurse Practitioner
Johns Hopkins All Children's Hospital
St Petersburg, Florida
Disclosure information not submitted.
I. Federico Fernandez Nievas
MD, MPA, CPE, FAAP
Johns Hopkins All Children's Hospital
St Petersburg, Florida, United States
Disclosure information not submitted.
Title: Pulmonary Embolism in an adolescent with Diabetic Ketoacidosis
Case Report Body:
Introduction: In some cases, children presenting with Diabetic Ketoacidosis (DKA) might need a central venous catheter for supportive care. This subgroup of patients is at increased risk for venous thrombosis. We present a case of an adolescent with DKA who developed an acute pulmonary embolism (PE) from a catheter-related thrombus.
Description: A 13-year-old male with no significant past medical history was admitted to the PICU with a new onset of DKA and shock. His presentation was positive for altered mental status, hypothermia, hypotension, and acute kidney injury. The initial laboratory was blood glucose 1298, PH 6.9, bicarbonate:1.9, and corrected plasma sodium 148. Since the patient required vasopressor support, a right internal jugular and arterial lines were placed for shock management and monitoring. Twenty-four hours later, he had an acute onset of respiratory distress, increased oxygen requirement, irritability with elevated D-dimer, and troponin levels. A CTA chest confirmed bilateral pulmonary embolism, and the CT head was negative for cerebral edema and stroke. A Doppler study showed nonocclusive large thrombi of the right brachiocephalic vein and a central line with nonocclusive thrombus in the right subclavian vein. Unfractionated heparin therapy was started and the patient clinical status improved.
Discussion: To our knowledge, there are few cases reported in the literature for CVL related Pulmonary Embolism in new-onset DKA pediatric patients. There is an association between hyperosmolar states and an increased risk of thrombosis. Thus, DKA is associated with a prothrombotic state through several mechanisms, including the hyperosmolar condition. For this reason, careful thought must be taken regarding the placement of central venous catheters and minimizing the duration in patients with DKA. A high index of suspicion is crucial for the diagnosis of pulmonary thromboembolism from asymptomatic catheter-induced thrombosis. Currently, there is insufficient evidence to support prophylactic anticoagulation to prevent catheter-related thrombosis for high-risk patients with DKA.