Fluid Therapy in Diabetic Ketoacidosis: Comparative Study

Abstract

H Salman, Fluid Therapy in Diabetic Ketoacidosis: Comparative Study. 1991; 11(2): 235-237 To the Editor. A life-threatening emergency, diabetic ketoacidosis, is a unique state of hyperglycemic hypertonic dehydration accompanied by ketotic acidemia. Its incidence is not declining and represents 67.2% of our population of newly diagnosed diabetic children in Riyadh. Treatment remains difficult, and mortality reported in the literature is still high, particularly in young children below 5 years of age and those with new onset [1,2,5]. The sudden development of cerebral edema, confirmed by computed tomography or on postmortem examination, during the first 24 hours of reasonable therapy for severe diabetic ketoacidosis remains poorly differentiated [1][2][3][4][5]. Contradictory reports have appeared that attempt to relate its occurrence to specific aspects of treatment, particularly to the overall fluid administration during the first 24 hours [3][4][5].We compared retrospectively two groups of patients treated with two different rehydration therapy protocols and administered by the same diabetic team at Suleimania Children's Hospital. Diagnosis of diabetic ketoacidosis was based on clinical findings (vomiting, abdominal pain, acidotic breathing, moderate to severe dehydration, torpor, or coma) and biological features (hyperglycemia > 15 mmol/L or 270 mg/dl) ketonuria, and metabolic acidosis (bicarbonate level, < 15 mmol/L). We reviewed the medical records of 38 patients of both sexes admitted to Suleimania Children's Hospital between 1987 and 1989 with a comparable mean age of onset (6 years 5 months in Group 1, 5 years 8 months in Group 2). The patients were newly diagnosed diabetics and presented similarly at onset with moderate to severe diabetic ketoacidosis. In 52.6% (20/38), metabolic acidosis was severe with pH < 7.1. Laboratory investigations and monitoring in the first 24 hours were similar for both groups. Blood gas analysis (capillary) and Hemoglukotest (using Reflolux 11 M device) were done every half hour for the first three hours, then hourly for the next 3 hours, then every three hours. Serum urea and electrolyte concentrations were determined initially and after three hours, then every four to six hours. Random urine electrolyte analysis was done initially and after 3 hours. Urine was examined for glucose, and ketone was tested whenever urine was passed. Urine output was monitored in the initial 24 hours of treatment in all patients. The protocol used in the 15 patients who made up Group 1 consisted of rehydration using an initial volume of 20 to 40 ml/kg over the first 2 hours then 3 L/m 2 over the remaining 22 hours using initially normal saline then ¼ normal saline D 5 % when blood glucose level reaches 16.6 mmol/L (300 mg/dl). For protocol 2, which comprised 23 patients, 5 to 10 ml/kg of normal saline was infused rapidly only if signs of shock were present, until correction of oliguria, turgor time, and blood pressure. Over 24 hours, the volume of fluids infused was 1 .5 L/m 2 (in cases of mo...