SGEM#255: It Don’t Matter Now – Fluid Type and Infusion Rate in Paediatric DKA

Date: April 29th, 2019 Reference: Kuppermann et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. NEJM June 2018 Guest Skeptic: Dr. Nikki Abela is a final year trainee in Emergency Medicine and Paediatric Emergency Medicine in Liverpool, UK from sunny Malta. She is a blog editor for RCEM Learning . She is a mum of one who wants to run. Case: 6-year-old Caroline is brought to the emergency department by her parents. She is known to have diabetes and has had diarrhea and vomiting for the last 24 hours. In spite of using her sick day regime of insulin, she still has “high” blood glucose readings and can not tolerate oral fluids. On her blood gas her pH is 7.1 and her glucose is 35 mmol/l (630mg/dl). You confirm her bedside ketones to be 6 and have secured a cannula (intravenous) ready to reverse her dehydration – but what fluids should you use and at what rate? Background: The study we are going to talk about today comes from PECARN (Pediatric Emergency Care Applied Research Network). They are a fantastic group that conducts high-quality, clinically relevant research in the management and prevention of acute injuries and illnesses in children. We’ve mentioned PECARN before when discussing pediatric traumatic brain injury (TBI) on SGEM#112. There is a similar group in the UK and Ireland. It is called PERUKI (Paediatric Emergency Research in UK and Ireland). Canada has something similar to PECARN called Pediatric Emergency Research Canada (PERC). They are “dedicated to improving care in pediatric emergency medicine through multi-centre research”.  Each country has their own pediatric research groups. These different groups often come up with a different clinical decision instruments, for example, to decide when to get neuroimaging in pediatric head trauma. There is the PECARN from the USA, CATCH Tool from Canada and the CHALLICE Tool from the UK. A study by Easter et al (Ann Emerg Med 2014) concluded that PECARN seemed to be the best of the three tools. But we are not talking about TBIs today we are talking about diabetic ketoacidosis (DKA). Almost 1% of children presenting with an episode of DKA exhibit clinically apparent brain injuries. These injuries are associated with morbidity and mortality (1-3).  It has been historically thought that the cerebral edema from rapid rehydration with IV fluids could be causing these injury (4-5).  As such, protocols recommend slow administration of IV fluids in children with DKA. Clinical Question: Does rate or sodium chloride content of intravenous fluids contribute to brain injuries in children with DKA? Reference: Kuppermann et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. NEJM June 2018 Population: Children 0-18 years of age with a diagnosis of DKA (blood glucose > 16.7 mmol/l or > 300 mg/dl, and either pH < 7.25 or a serum bicarbonate level of < 15 mmol/l) Key Exclusions: “Underlying disorders that could affect mental status testing or neurocognitive evaluation; concurrent alcohol or narcotics use, head trauma or other conditions that could affect neurologic function; diabetic ketoacidosis for which the patient had already received substantial treatment; known pregnancy; or factors for which treating physicians determined that a specific fluid and electrolyte therapy was necessary. Children who presented with a Glasgow Coma Scale score of 11 or lower (on a scale ranging from 3 to 15, with lower scores indicating worse mental status) were excluded after year 2 because many participating clinicians believed that fluid regimens for such children should not be deter- mined on the basis of randomization.” Intervention: Fast rehydration (20ml/kg bolus) with either 0.45% or 0.9% NaCl (assumed 10% deficit with half being replaced in first 12 hours with the rest in the next 24hrs plus maintenance fluid). Insulin 0.1u/kg/hr IV Comparison: Slow rehydration (10ml/kg bolus) with 0.