title: Low morbidity and mortality in children with diabetic ketoacidosis treated with isotonic fluids.
abstract: OBJECTIVE
  To assess current rates of complications of diabetic ketoacidosis (DKA), particularly cerebral edema, in a large tertiary-care pediatric hospital with a consistent management protocol.
  
  
  METHODS
  We report our single-center retrospective experience with 3712 admissions with DKA in 1999-2011. Our DKA protocol features a "3-bag" system using 2 bags of rehydration fluids, identical except for the presence in 1 bag of 10% dextrose, to allow rapid adjustment of glucose infusion rate. The third bag contains insulin. Fluids are administered at a total rate of 2-2.5 times "maintenance" fluid requirements. Total electrolyte concentration is kept approximately isotonic. Billing and medical records databases at Children's Medical Center Dallas were examined for cases of DKA, cerebral edema, other morbidities, and death.
  
  
  RESULTS
  We ascertained 20 cases of cerebral edema (0.5%). Most presented early (median duration of treatment 2 hours). Only 10 of 20 computed tomography scans were graded as moderate edema or worse. Only 10 patients received treatment other than routine DKA management. There was 1 death in a patient with sickle cell trait who developed intravascular sickling. Two patients had neurologic sequelae at hospital discharge but both recovered fully.
  
  
  CONCLUSIONS
  Compared with data in recent consensus statements, the Dallas protocol is associated with extremely low rates of death and disability (0.08% vs 0.3%) from DKA.
authors.affiliation: Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center and Children's Medical Center, Dallas, TX 75390-9063, USA. Perrin.white@utsouthwestern.edu
authors.forename: Perrin C
authors.initials: PC
authors.lastname: White
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Dickson
mesh_terms: D000293:Adolescent; D001929:Brain Edema / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003131:Combined Modality Therapy; D016883:Diabetic Ketoacidosis / Q000150:complications / Q000401:mortality / Q000628:therapy*; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D005947:Glucose / Q000627:therapeutic use*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D007552:Isotonic Solutions; D008297:Male; D015532:Rehydration Solutions / Q000627:therapeutic use*; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin; D007552:Isotonic Solutions; D015532:Rehydration Solutions; D005947:Glucose
keywords: ADA; American Diabetes Association; CT; Computed tomography; DKA; Diabetic ketoacidosis; ICD-9; International Classification of Diseases, Ninth Revision; NaCl; Sodium chloride