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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.

Search Outcome

178 papers were found, of which 2 answered the 3 part clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Edge, J September 2006 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],
Sarah E. Lawrence MD, FRCPC May 2005 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)

Clinical 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

1. Edge, J The UK case–control study of cerebral oedema complicating diabetic ketoacidosis in children Diabetologia (2006) 49:2002–2009
2. Sarah E. Lawrence MD, FRCPC Population-based study of incidence and risk factors for cerebral oedema in Paediatric Diabetic Ketoacidosis The Journal of Pediatrics May 2005, Pages 688-692