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

Version 3 2021-06-29, 16:32
Version 2 2021-06-29, 16:31
Version 1 2021-06-29, 16:28
posted on 2021-06-29, 16:32 authored by Arleta Rewers, Nathan Kuppermann, Michael J. Stoner, Aris Garro, Jonathan E. Bennett, Kimberly S. Quayle, Jeffrey E. Schunk, Sage R. Myers, Julie K. McManemy, Lise E. Nigrovic, Jennifer L. Trainor, Leah Tzimenatos, Maria Y. Kwok, Kathleen M. Brown, Cody S. Olsen, T. Charles Casper, Simona Ghetti, Nicole S. Glaser, the Pediatric Emergency Care Applied Research Network (PECARN) DKA FLUID Study Group
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.


This study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (U01HD062417). This project was also supported in part by the Health Resources and Services Administration, Maternal and Child Health Bureau, and Emergency Medical Services for Children Network Development Demonstration Program under cooperative agreement numbers U03MC00008, U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC22684, and U03MC22685. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, Health Resources and Services Administration, Health and Human Services, or the U.S. government.


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