Physiologic management of diabetic ketoacidemia. A 5-year prospective pediatric experience in 231 episodes.

OBJECTIVE: To determine whether gradual rehydration in moderate and severe diabetic ketoacidemia (DKA) can safely prevent untoward declines in calculated effective osmolality (Eosm) early in treatment and, hence, help prevent major central nervous system complications.
DESIGN: Prospective study.
SETTING: Three tertiary care hospitals. PATIENTS: Two hundred thirty-one consecutive episodes of DKA in 149 patients aged 10 months to 20 years admitted during a 5-year period.
INTERVENTIONS: Insulin therapy in addition to rehydration using an estimated volume of deficit with planned administration over 48 hours; initial administration of rehydration solutions with an osmolality approximating that of the patient; and intensive patient monitoring. MEASUREMENTS: Mean lowest calculated Eosm (EosmL) during the first 24 hours of treatment; trend of the concentration of sodium in serum in the first 12 hours of treatment; comparison of pretreatment serum concentrations of glucose, urea nitrogen, and corrected sodium between mildly and very severely dehydrated patients; and patient outcome.
RESULTS: A mean (+/- SD) EosmL of 285.8 +/- 10.5 mOsm/kg Nater and an increase in the concentration of sodium in serum in 90% of episodes were documented. There were statistically significant differences in serum concentrations of glucose, urea nitrogen, and corrected sodium in mildly vs very severely dehydrated patients. There were no deaths or near-death episodes.
CONCLUSIONS: Management of moderate and severe DKA with a 48-hour planned rehydration is safe and prevents untoward declines in Eosm. Coupled with intensive monitoring, gradual rehydration can protect against life-threatening increases in intracranial pressure and brain herniation.