title: Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema.
abstract: OBJECTIVE
  To compare outcomes of diabetic ketoacidosis (DKA) 6 yrs before and 6 yrs after changing rehydration fluids from ½ normal saline to Lactated Ringer's and decreasing the total intended fluid volume administered in the first 24 hrs from 3500 mL/m(2) /d to ≤ 2500 mL/m(2) /d at Texas Children's Hospital (TCH) in response to recommendations by the ESPE, LWPES, and ISPAD in 2004.
  
  
  METHODS
  A retrospective cohort study was conducted in which 1868 admissions for DKA were identified and reviewed. The cohort was divided into two groups: Group A, 1998-2004, and Group B, 2004-2010. Subjects with suspected clinical cerebral edema and adverse outcomes were identified.
  
  
  RESULTS
  Although not statistically significant, there was an equal number (n = 3) of adverse outcomes (death or neurological damage) in each group despite more than double the admissions in Group B (1264) compared with those in Group A (604). Overall, the incidence of suspected clinical cerebral edema was more than double for those admissions in which fluid resuscitation was initiated at an outside hospital (OSH) vs. at TCH (13.6 vs. 5.3%, p < 0.001).
  
  
  CONCLUSIONS
  Decreasing the intended fluid rate during the initial 24 hrs to 2500 mL/m(2) /d and increasing the IV fluid sodium content did not significantly decrease the incidence of adverse outcomes in children with DKA. However, children transferred from an OSH had a higher incidence of suspected clinical cerebral edema. Thus, we need to more readily share our management protocols with the emergency rooms of local referring hospitals to potentially decrease the incidence of suspected clinical cerebral edema and adverse outcomes in children transferred with DKA.
authors: Division of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA.
authors: Daniel S
authors: DS
authors: Hsia
authors: Baylor College of Medicine, Medical School, Houston, TX 77030, USA.
authors: Sarah G
authors: SG
authors: Tarai
authors: Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA.
authors: Amir
authors: A
authors: Alimi
authors: Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA.
authors: Jorge A
authors: JA
authors: Coss-Bu
authors: Division of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA.|Department of Pediatrics, Children's Nutrition Research Center, U.S. Department of Agriculture/Agricultural Research Service, Baylor College of Medicine, Houston, TX 77030, USA.
authors: Morey W
authors: MW
authors: Haymond
mesh_terms: D000293:Adolescent; D001929:Brain Edema / Q000453:epidemiology* / Q000209:etiology; D002648:Child; D016883:Diabetic Ketoacidosis / Q000150:complications / Q000453:epidemiology* / Q000628:therapy*; D005260:Female; D005440:Fluid Therapy / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007552:Isotonic Solutions / Q000627:therapeutic use; D008297:Male; D012189:Retrospective Studies; D000077325:Ringer's Lactate; D012965:Sodium Chloride / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D007552:Isotonic Solutions; D000077325:Ringer's Lactate; D012965:Sodium Chloride
keywords: cerebral edema; diabetic ketoacidosis; practice guidelines