Pediatric Diabetic Ketoacidosis Management in the Era of Standardization

Ildiko H Koves; Catherine Pihoker


Expert Rev Endocrinol Metab. 2012;7(4):433-443. 

In This Article

Fluid Therapy

Fluid Resuscitation

Patients with DKA are generally dehydrated. Clinical assessment of severity of dehydration is likely to be inaccurate, under- or over-estimated, with little agreement between the clinician-assessed and the measured degree of dehydration.[30] Other studies have shown a tendency to overestimate the degree of dehydration[31,32] and, as such, overzealous fluid resuscitation regimens may lead to further complications. A prospective surveillance study in the UK found that the amount of fluids used in the first 4 h of therapy was associated with an increased risk of CE.[33] Therefore, initial volume resuscitation should be performed with isotonic fluids in 10 ml/kg bolus increments, with repeat boluses only if the patient is hemodynamically unstable. Incremental total fluid bolus resuscitation should not exceed 30–40 ml/kg total volume, unless the patient remains in overt shock. As patients may be transferred from one facility to another in the course of their treatment, fluid administration at all sites of care needs to be managed accordingly.

Fluid Deficit Replacement

Most patients are 5–10% dehydrated; therefore, it is safe to assume a 7% dehydration level to work out the fluid replacement amount to be given over 48 h. The most helpful signs for the assessment of dehydration are prolonged capillary refill time (>2 s) and abnormal skin turgor (tenting of the skin).

Other useful signs to aid hydration state assessment are dry mucous membranes, sunken eyes, absent tears, cool extremities and sunken fontanelle in the very young. If weak and impalpable peripheral pulses, oliguria and hypotension are present, a more severe degree of dehydration (i.e., ≥10%) is likely to be present.

The fluid rate calculation should also include consideration for large amount of oral fluids consumed. There are no current guidelines on how to include prearrival oral fluid consumption, and such a calculation relies on physician judgment. Fluid replacement should be with isotonic fluids, such as normal saline, initially in the first 4–6 h of therapy,[3] and switched to half normal saline when corrected sodium is normalized. In the setting of hyponatremia, a fall in corrected sodium or significant hypernatremia isotonic fluid therapy may need to continue up to 12 h. However, prolonged normal saline therapy may lead to complications, in particular hyperchloremic acidosis. Recent attention has been given to the sodium contents of the rehydration fluids, in particular, during the first 8 h, although there is no convincing evidence of an association between the rate of fluid or sodium administration used to treat DKA and the development of CE.[3] Experts have considered using hypertonic saline therapy,[34] especially, in the first 8 h of therapy. More research is needed in this area before this therapy can be safely recommended.


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