LR vs NS for Pediatric DKA

Written by Clay Smith

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Use of any LR in pediatric patients with DKA, as opposed to only NS, was associated with lower overall costs, similar length of stay, and markedly reduced incidence of cerebral edema in this retrospective study.

Why does this matter?
Given the results of the SMART and SALT-ED trials, balanced crystalloids appear to be better for patients.  We also know that rate of fluid administration and use of 1/2NS compared with NS did not make a difference in cerebral edema for pediatric patients with DKA.  How does use of NS or LR impact pediatric DKA?

LR wins again
This was a retrospective review of a large pediatric health database that reviewed over 45,000 cases of pediatric DKA.  Only 4% received only LR, while 8% received both NS and LR.  The remaining 88% received NS.  They found that use of any LR was associated with lower overall costs, similar length of stay, and markedly reduced incidence of cerebral edema.  Over the study period, NS was increasingly used, likely a result of guidelines based on expert opinion that recommended NS.  And as NS use increased, so did the incidence of cerebral edema.  Firm conclusions cannot be drawn from a retrospective study with innumerable potential confounders, but taken in light of the recent SMART and SALT-ED trials, it suggests a switch to LR or other balanced crystalloid may improve outcome for children with DKA.

Source
Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis.  Pediatr Emerg Care. 2018 Jul 16. doi: 10.1097/PEC.0000000000001550. [Epub ahead of print]
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