Arleta Rewers1, Nathan Kuppermann2,3, Michael J Stoner4, Aris Garro5, Jonathan E Bennett6, Kimberly S Quayle7, Jeffrey E Schunk8, Sage R Myers9, Julie K McManemy10, Lise E Nigrovic11, Jennifer L Trainor12, Leah Tzimenatos2, Maria Y Kwok13, Kathleen M Brown14, Cody S Olsen8, T Charles Casper8, Simona Ghetti15, Nicole S Glaser3. 1. Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora arleta.rewers@childrenscolorado.org. 2. Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento. 3. Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento. 4. Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH. 5. Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI. 6. Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA. 7. Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO. 8. Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT. 9. Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 10. Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX. 11. Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA. 12. Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL. 13. Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY. 14. Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC. 15. Department of Psychology and the Center for Mind and Brain, University of California, Davis, Davis, CA.
Abstract
OBJECTIVE: Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment. RESEARCH DESIGN AND METHODS: The current analysis involved moderate or severe DKA episodes (n = 714) in children age <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial. Children were assigned to one of four treatment groups using a 2 × 2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration). RESULTS: The rate of change of pH did not differ by treatment arm, but Pco2 increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%). CONCLUSIONS: In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco2 than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.
OBJECTIVE: Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment. RESEARCH DESIGN AND METHODS: The current analysis involved moderate or severe DKA episodes (n = 714) in children age <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial. Children were assigned to one of four treatment groups using a 2 × 2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration). RESULTS: The rate of change of pH did not differ by treatment arm, but Pco2 increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%). CONCLUSIONS: In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco2 than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.
Authors: Joseph I Wolfsdorf; Nicole Glaser; Michael Agus; Maria Fritsch; Ragnar Hanas; Arleta Rewers; Mark A Sperling; Ethel Codner Journal: Pediatr Diabetes Date: 2018-10 Impact factor: 4.866
Authors: S Fredheim; J Johannesen; A Johansen; L Lyngsøe; H Rida; M L M Andersen; M H Lauridsen; B Hertz; N H Birkebæk; B Olsen; H B Mortensen; J Svensson Journal: Diabetologia Date: 2013-02-07 Impact factor: 10.122
Authors: Simona Ghetti; Nathan Kuppermann; Arleta Rewers; Sage R Myers; Jeff E Schunk; Michael J Stoner; Aris Garro; Kimberly S Quayle; Kathleen M Brown; Jennifer L Trainor; Leah Tzimenatos; Andrew D DePiero; Julie K McManemy; Lise E Nigrovic; Maria Y Kwok; Clinton S Perry; Cody S Olsen; T Charles Casper; Nicole S Glaser Journal: Diabetes Care Date: 2020-09-22 Impact factor: 19.112
Authors: Eda Cengiz; Dongyuan Xing; Jenise C Wong; Joseph I Wolfsdorf; Morey W Haymond; Arleta Rewers; Satya Shanmugham; William V Tamborlane; Steven M Willi; Diane L Seiple; Kellee M Miller; Stephanie N DuBose; Roy W Beck Journal: Pediatr Diabetes Date: 2013-03-08 Impact factor: 4.866
Authors: Tandy Aye; Paul K Mazaika; Nelly Mauras; Matthew J Marzelli; Hanyang Shen; Tamara Hershey; Allison Cato; Stuart A Weinzimer; Neil H White; Eva Tsalikian; Booil Jo; Allan L Reiss Journal: Diabetes Care Date: 2018-12-20 Impact factor: 19.112