Jeff Burzynski raises an interesting point about the danger of the hyperosmolar state and risk of thrombosis. In the patient that we described (a 6-year-old girl with DKA and stroke),1 the initial serum sodium level was 132 mmol/L and initial blood glucose, 43.4 mmol/L. The corrected sodium level was 144 mmol/L with a calculated serum osmolarity of 331 mOsm/L. We agree that patients with DKA have hyperosmolarity because of hyperglycemia and hypernatremic dehydration, and we1 and others2,3 have suggested that the hyperosmolarity contributes to the prothrombotic tendency of children with DKA.
Worly and associates2 described 3 patients aged 14–18 months with DKA and calculated serum osmolarity of 291–356 mOsm/L who experienced deep venous thrombosis associated with central venous femoral catheters. Similarly, Gutierrez and colleagues3 described 4 patients 1 month to 3 years of age with serum osmolarity of 280–330 mOsm/L who experienced the same problem in association with central venous femoral catheters. Although the patient in our case did not have a central venous line and was older than the patients previously described, her calculated serum osmolarity was similar. The extreme hypernatremia (sodium 213 mmol/L) and hyperosmolarity (calculated serum osmolarity 556 mOsm/L) described in a 2-week-old breast-feeding baby who experienced transverse sinus thrombosis4 was much more severe than what was seen in our patient.
Despite the reported association between DKA and prothrombotic state, at our centre we do not routinely use prophylactic anticoagulation in patients with DKA and a hyperosmolar state. Current international consensus statements5 and Canadian clinical practice guidelines6 on the management of DKA in children also do not address this issue, and prophylactic anticoagulation is not recommended. We concur that further clinical trials are required to determine the safety and efficacy of prophylactic anticoagulation in children with DKA.
Josephine Ho Pediatric Endocrine Fellow Danièle Pacaud Division Chief Division of Pediatric Endocrinology Jean Mah Pediatric Neurologist Division of Pediatric Neurology Alberta Children's Hospital Calgary, Alta.
Footnotes
Competing interests: None declared.
References
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