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Three Part Question

In [an adult without signs of shock] is [lower volume paediatric fluid regime safer than high adult volumes] At [treating diabetic Ketoacidosi]?

Clinical Scenario

18 year old woman attends the ED with DKA but no signs of shock. She weighs 50kg and is over the age limit for paediatric guidelines. However you realise that the volume difference between the two protocols is almost double. You wonder if in an adult a lower volume regime would be safer.

Search Strategy

Using the National Library for health the following data bases were searched, Medline 1950- present, EMBASE 1980-present using the following strategy. (fluid* OR crystalloid OR colloid) AND (Diabetic AND Ketoacidosis) AND Adult.
The most recent guidelines were sought using google scholar and NICE their references reviewed.
Guideline used ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents 2004

Search Outcome

Medline produced 15 papers, 1 of relevance,
EMBASE produced 19 papers with the same paper as Medline.
From the search of references 3 papers were identified

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Atchley DW, Loeb RF, Richards DW, Benedict EM, Driscoll ME 1932 USA	two male patients age 19 and 25	Metabolic balance study of induced diabetic ketoacidosis by the withdrawal of insulin in two diabetic patients.	only one patient became acidotic	Subject lost 1.2 kg wieght and a total of 4.3 ltrs.	No ability to measure insensible losses. Only one patient acidotic in artificial surroundings Study over 70 years old
Nabarro JDN, Spencer, AG, Stowers JM 1952 UK	19 patients aged 12-64	Metabolic balance studies of 19 patients recovering from DKA.		mean fluid retention 4.6ltr over study period. 2.9ltr over 72 hours to correct extracellular volume	Different treatment regime from today and not standardised between patients in paper. No patient morbidity/complication data
Adroge HJ, Barrero J, Exnoynan G, 1989 USA	23 patients with DKA aged 16-57	23 patients attending with DKA randomised to either a high volume or low volume group for fluid replacement. Excluded if signs of shock or renal insufficiency.	comparison of two fluid protocols, one using half the volumes of usual practice to assess safety	Recovery was slower in the higher volume group.	Small numbers in a single centre with no evidence of power calculations to detect the rarer complications. Method of randomisation is not covered in the paper
GD Harris, I Fiordalisi, WL Harris, LL Mosovich, L Finberg 1990 USA	two studies in one paper retrospective part; 219 episodes of DKA over 25 years ages 13 months to 30 years prospective part; 58 episodes of DKA over one year aged 1.5 years to 20 year old.	Retrospective part; Notes identified by discharge diagnosis and reviewed for therapy given, paired sodium-glucose values and their trend, tonicity and weight change. Prospective part; Individualised 48hr rehydration schedule allowing even infusion of fluid.	retrospective; compare episodes of DKA with complications to those without and review the trend of sodium concentration and fluid therapy given. Prospective; Review the effect of individualised treatment scheduke on lowering osmolality slowly.	Fewer complications found in the prospective arm	No power calculations. Seems the prospective arm too small to detect the complication rate found in the retrospective arm. Treatment regimes changed during retrospective study and could alter results. Prospective arm mainly paediatric population

Comment(s)

There are no recent high quality studies addressing this issue. Androgue has attempted to address this issue in 1989 but the study is small and probably has not enough power to detect rare complications like cerebral oedema of which there are case reports in adults.

Clinical Bottom Line

While there is no clear evidence for the safety of lower amounts of fluid calculated by patient weight in adults local guidelines should be followed and care taken in those who would recently have been called paediatric.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Atchley DW, Loeb RF, Richards DW, Benedict EM, Driscoll ME On Diabetic Acidosis, a detailed study of electrolyte balances following the withdrawal and reestablishment of insulin therapy Journal Clinical Investigation March 1933 12:297-326
2. Nabarro JDN, Spencer, AG, Stowers JM Metabolic Studies in Severe Diabetic Ketosis Quarterly Journal of Medicine 1952; 21:225-248
3. Adroge HJ, Barrero J, Exnoynan G Salutary Effects of Modest Fluid Replacement in the Treatment of Adults With Diabetic Ketoacidosis; Use in Patients Without Extreme Volume Deficit JAMA 1989; 262 (15) 2108-13
4. GD Harris, I Fiordalisi, WL Harris, LL Mosovich, L Finberg Minimising the Risk of Brain Herniation During Treatment of Diabetic Ketoacidaemia: A Retrospective and Prospective Study Journal of Paediatrics 1990 117:22-31;