Fluid resuscitation in childhood diabetic ketoacidosis
Date First Published:
July 17, 2009
Last Updated:
July 30, 2009
Report by:
Joanna Ibhadon, 4th Year Medical Student (Unviersity of Manchester)
Three-Part Question:
In a [child with DKA], should the [resuscitation fluid be subtracted from the maintenance of fluid] in order to [reduce the risk of cerebral oedema]?
Clinical Scenario:
A 10 year old female with DKA is being resuscitated with fluids in the Emergency Department. After a thorough assessment of hydration status and calculation of her maintenance requirements, you decide to calculate the hourly fluid rate for her treatment. However, you are aware that you gave the patient fluids as soon as she was admitted in order to quickly resuscitate the patient and correct peripheral circulation. The paediatric registrar arrives and tells you that you need to subtract your resuscitation bolus from the maintenance and deficit requirements. You wonder if there is any evidence for this if the risk of cerebral oedema would increase without the subtraction of the fluid bolus.
Search Strategy:
Medline (1950-07/09) using the OVID interface, Cochrane (2009) and Embase (2009)
[Fluid.mp] OR [Cerebral Oedema.mp] AND [exp.Diabetic ketoacidosis]. LIMIT to human AND children aged 0-18 AND English language.
[Fluid.mp] OR [Cerebral Oedema.mp] AND [exp.Diabetic ketoacidosis]. LIMIT to human AND children aged 0-18 AND English language.
Outcome:
178 papers were found, of which 2 answered the 3 part clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The UK case–control study of cerebral oedema complicating diabetic ketoacidosis in children Edge, J Sep-06 UK | patients under 16 who died during the assessment or treatment of DKA 16 over a 3-year period |
UK case–control study | Insulin administration | Insulin given during the first hour was associated with risk (OR 12.7 [1.41–114.5], p=0.02) | -No power -Unmatched cases and controls |
| Fluid volume | Volume of fluid administered over the first 4 h (OR 6.55 [1.38–30.97], | ||||
| Population-based study of incidence and risk factors for cerebral oedema in Paediatric Diabetic Ketoacidosis Sarah E. Lawrence MD, FRCPC May-05 Canada | Cases are patients with DKA <16 years of age with cerebral edema. Two unmatched control subjects per case are patients with DKA without cerebral edema. |
Population-based study | BUN | BUN Odds ratio of 1.42 (95% CI, 1.08 to 1.88; P = .013). | |
| Initial bicarbonate | Lower initial bicarbonate (P = .001) | ||||
| Urea | Higher initial urea (P = .001) | ||||
| Glucose | Higher glucose at presentation (P = .014). | ||||
| Fluid infusion rate | High rate of fluid infusion(p=0.090) | ||||
| Sodium | Sodium(p=0.012) |
Bottom Line:
No association was found between the occurrence of cerebral oedema and treatment factors.Patients should be treated with appropriate fluids for resuscitation, based on local guidelines.
References:
- Edge, J . The UK case–control study of cerebral oedema complicating diabetic ketoacidosis in children
- Sarah E. Lawrence MD, FRCPC. Population-based study of incidence and risk factors for cerebral oedema in Paediatric Diabetic Ketoacidosis