We recently debated the initial fluid management of children
presenting with severe diabetic ketoacidosis (DKA). A hypothetical case
--an 8 month-old male infant with new onset DKA, a heart rate of 190 with
poor peripheral perfusion, but not hypotensive. Glucose 1054 mg/dL, pH
(arterial) 7.03, pCO2 10, serum Na 145 meq/L, chloride 113, potassium 3.3,
HCO3 less than 5, BUN 35 mg/dL, creatinine 1.7 mg/dL, lactate 2.1 meq/L.
Discussion centered around two issues.
I. Which components of the evaluation predict intravascular volume
depletion (compensated shock) in the setting of concurrent acidosis and
II. What are the risks, if any, of rapid infusions of normal saline
in pediatric patients with severe DKA? Which patients need rapid expansion
of intravascular volume? How much?
Which respect to these issues, how would you respond to the following
Capillary refill time is primarily increased secondary to acidosis and does
not imply compensated shock in this setting.
Tachycardia results from increased epinephrine as part of the excess of
counter-regulatory hormones, and therefore may not imply volume depletion.
A normal lactate implies the absence of significant intravascular volume
depletion, therefore, if lactate is normal, a normal saline bolus not
The rapid initial decline in serum glucose associated with improved renal
perfusion increases the risk of cerebral edema.
Too vigorous initial fluid resuscitation with "isotonic" fluids given in
the ED predisposes patients with DKA and other hyperosmolar states to
I look forward to your learned replies...
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Dale Steele, M.D. Assistant Prof. of Pediatrics
Pediatric Emergency Medicine Brown University
Potter 212, Rhode Island Hospital Voice: (401)444-6236
593 Eddy St. Fax: (401)444-4569
Providence, RI 02903 USA
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