Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children With Diabetic Ketoacidosis

IMPORTANCE: Fluid replacement to correct dehydration, acidosis and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA) but little is known about optimal fluid infusion rates and electrolyte content.

OBJECTIVE: To evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment.

DESIGN, SETTING, PaRTICIPANTS: The current analysis involved moderate or severe DKA episodes (n=714) in children <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial.

INTERVENTION: Children were assigned to one of four treatment groups using a 2-by-2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration).

Results: The rate of change of pH did not differ by treatment arm, but PCO₂ increased more rapidly in the fast vs slow fluid infusion arms during the initial 4 hours of treatment. The anion gap also decreased more rapidly in the fast vs slow infusion arms during the initial 4 and 8 hours. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 hours. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% vs 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) vs slow arms (35.2%).

CONCLUSIONS AND RELEVANCE: In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and PCO₂ than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.