Brain Injury in DKA | Fluid Rate or Type RCT by PECARN

July 20, 2018

Written by Clay Smith

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Neither the fluid rate (fast or slow) or type (NS vs 1/2NS) altered the risk of brain injury with decline in GCS <14 in children with DKA.

Why does this matter?
Whether the type or rate of IV fluid used in DKA increases the risk of brain injury and subsequent cerebral edema has been a subject of intense and longstanding debate.  This study helps clarify this question.

The fluid is not the culprit
This was a multi-center 2×2 factorial RCT in 1389 children with DKA, with NS given fast or slow or 1/2NS given fast or slow. Treatment groups were as per Table 1.

The primary outcome was decline in GCS <14, which occurred in 45 patients, evenly split among the 4 groups, with no statistical difference between them.  Secondary outcomes looking at more subtle neurologic dysfunction (memory and IQ scores) were not affected by any of the tested variables.  This tells us that it is not the type of fluid or infusion rate that causes brain injury in DKA.

Source
Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis.  N Engl J Med. 2018 Jun 14;378(24):2275-2287. doi: 10.1056/NEJMoa1716816.
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Reviewed by Thomas Davis

Another Spoonful
This mythbuster piece from emDOCs is required reading.