Fluids in Pediatric DKA

Dr. Ryan Gluth


Cerebral edema is one of the most feared complications in pediatric patients with diabetic ketoacidosis (DKA). It is the leading cause of death from this disease process. Thankfully cerebral edema is a rare complication, occurring in less than 1% of patients¹. Although there is a paucity of evidence to support this practice, traditional teaching recommends cautious use of IV fluids due to the risk of inducing cerebral edema. These recommendations come from retrospective reviews and case studies not randomized controlled trials.

Does IV fluid infusion rate or sodium content of crystalloids influence neurologic outcomes of children with DKA?


Kuppermann et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. New England Journal of Medicine 2018. 


Study Design

This study was a prospective, multicenter, randomized control trial. Children <18 years old who presented in DKA to 13 different emergency departments within the PECARN network were randomly assigned to one of four treatment groups as seen below. The primary outcome assessed was the number of episodes of decline in GCS to less than 14. Two secondary outcomes were also assessed including the incidence of clinically apparent brain injury and short term memory deficits. Clinically apparent brain injury was defined as clinical deterioration requiring intubation, hyperosmolar therapy, or result of death. Memory was assessed during treatment with digit span recall testing and memory testing at 3 months. Children presenting with GCS less than 14 at time of enrolment were not included in the primary analysis.



In this prospective randomized controlled trial the rate of IV fluid administration and sodium chloride content did not affect neurologic outcomes in patients presenting with a GCS of 14 or greater. 



¹ Walls, R. M. (2018). Rosen’s Emergency Medicine Concepts and Clinical Practice.

Philadelphia, PA: Elsevier.