Background: Fluid replacement to correct acidosis and electrolyte abnormalities is the cornerstone of treatment of diabetic ketoacidosis (DKA). We evaluated the rates of change in pH, pCO2, anion gap, Na, K, and Cl in children randomized to four DKA fluid treatment protocols.

Methods: From a large study conducted by The Pediatric Emergency Care Applied Research Network we used data from 714 children <18 y old with moderate or severe DKA. In a 2-by-2 factorial design, we evaluated the effects of intravenous rehydration with 0.9% vs. 0.45% NaCl and fast vs. slow rate of fluid administration, after an initial 0.9% NaCl bolus. The fast arm assumed 10% dehydration - half replaced in 12 h + maintenance fluids, the other half replaced over subsequent 24 h + maintenance fluids. The slow arm assumed 5% dehydration replaced evenly over 48 hours + maintenance fluids. We tested for differences in the rate of change of laboratory values between treatments using stratified Van Elteren and Cochran Mantel Haenszel tests.

Results: The median age, sex, and baseline laboratory characteristic of the patients did not differ by treatment arm. The rate of change of pH did not differ by the arm, however the rate of rise of pCO2 was more rapid in the fast vs. slow fluid arms during the initial 4 h. The rate of decrease in anion gap was more rapid in the fast vs. slow arms during the initial 4 h and 8 h (p<0.01 for all). Glucose-corrected Na remained steady for subjects assigned to 0.9% NaCl vs. those assigned to 0.45% NaCl whose glucose-corrected Na decreased at 4 and 8 h (p<0.01). K levels decreased and Cl increased more rapidly with 0.9% vs. 0.45% NaCl (p<0.01). Hyperchloremic acidosis developed in 46.1% of patients in the fast arms vs. 35.2% in the slow arms (p<0.01).

Conclusions: In children treated for DKA, faster fluid administration led to more rapid normalization of anion gap and pCO2 than slower fluid rates. However, more rapid fluid rates were associated with increased frequency of hyperchloremic acidosis.


A. Rewers: None. N.D. Kuppermann: Other Relationship; Self; InsuCalc. M.J. Stoner: None. A. Garro: None. K. Quayle: None. J.E. Bennett: None. S. Myers: None. J.K. McManemy: None. L.E. Nigrovic: None. J.L. Trainor: None. L. Tzimenatos: None. M. Kwok: None. C.S. Olsen: None. T.C. Casper: None. S. Ghetti: None. N. Glaser: Consultant; Self; Bristol-Myers Squibb Company. Other Relationship; Self; Insucalc.


Eunice Kennedy Shriver National Institute of Child Health and Human Development

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