DKA Fluid Choice, Dropping Sodium, and AMS – Is There Correlation?

September 15, 2021

Written by Clay Smith

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In pediatric patients with DKA, a decline in serum sodium was associated with a higher starting sodium level, preexisting diabetes, and use of 0.45% saline. Patients with a drop in sodium during treatment did not have an associated increase in altered mental status.

Why does this matter?
DKA patients often have hyponatremia, even after correcting for hyperglycemia. But some start with a normal to high sodium, especially if they have greater free water loss for some reason. Prior retrospective studies showed an association of falling sodium concentration with cerebral edema and brain injury. But is this correct?

More PECARN FLUID insights

• Design: This was a secondary analysis of the PECARN FLUID RCT, comparing rate and composition of IV fluid in pediatric DKA patients.

• Results: Three factors were associated with a drop in glucose-corrected sodium concentration: a higher starting serum sodium, preexisting diabetes, and use of 0.45% saline. Fluid rate had minimal effect. An important secondary outcome was that patients who had a drop in serum sodium, vs those who remained stable or increased, did not have an associated increase in altered mental status or cerebral edema.

• Implications: A drop in glucose-corrected serum sodium did not appear to increase risk for cerebral edema in children with DKA. Practically speaking, this means that use of hypotonic fluid for maintenance in DKA is probably OK.

• Limitations: Though this was a secondary analysis of previously collected prospective data. The original RCT was not designed to detect these outcomes.

Source
Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis. Pediatrics. 2021 Aug 9;e2021050243. doi: 10.1542/peds.2021-050243. Online ahead of print.