A few children experience cognitive impairment and cerebral edema following the resuscitation phase of diabetic ketoacidosis. For many years, there has been suspicion the rapid volume replacement with isotonic crystalloids precipitated cerebral edema, leading to protocols requiring conservative rates of fluid administration.
Probably unnecessarily so.
This 2×2 randomized trial tested “fast” versus “slow” fluid resuscitation, as well as isotonic 0.9% saline versus 0.45% saline. “Fast” resuscitation repleted a 10% body weight fluid deficit with half of the fluid in the first 12 hours, while the “slow” resuscitation repleted a 5% fluid deficit at a steady rate over 48 hours. A little more than three hundred patients were included in each arm, with the primary outcome being a decline in mental status as measured by the Glasgow Coma Score. Persistent cognitive impairment, “clinically apparent brain injury”, and other adverse events were tracked as secondary outcomes.
Effectively, there is no discernable difference in outcomes between the four groups. Deterioration of mental status and clinically apparent brain injury were rare – occurring, essentially, around the expected 0.5-1.0% rate regardless of resuscitation speed or fluid selection. Serious adverse events were uncommon and similar across groups, without reliable signals of inferiority to any specific resuscitation strategy.
Whatever you’ve been doing these last few years, at least, hasn’t been “wrong”. Unfortunately, having failed to identify this as a preventable trigger for cerebral injury in DKA, the search for its cause must go on.
“Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis”
https://www.nejm.org/doi/full/10.1056/NEJMoa1716816