Is Intravenous Fluid Therapy Associated with Cerebral Oedema in Paediatric Diabetic Ketoacidosis? Literature Review and Critical Appraisal of Evidence

Objective: The ongoing controversy regarding fluid management in pediatric diabetic ketoacidosis (DKA) has necessitated this review of whether aggressive fluid therapy aggravates the risk of cerebral edema. The amount of fluid administered in pediatric DKA is estimated with a weight-based formula for correction of deficit, dehydration, and fluids maintenance. Cerebral edema is known to occur with hyperosmolar treatment or controlled hyperventilation treatment for cerebral edema.

Methods: A literature search was conducted using EMBASE, Medline, and Cochrane databases for systematic reviews and original articles published in the last 18 years from the year 2000 to 2018 using search words individually or in combination, Inclusion criteria were studies limited to pediatric patients treated for diabetic ketoacidosis. In addition, a critical appraisal of the most current evidence was performed.

Results: After the literature search, 913 articles were identified from Medline, Embase, and Cochrane databases. Non-relevant studies, non-full text studies, and studies that lacked control groups or articles that were duplicated were excluded leaving a final total of five full test articles for literature review and critical appraisal of evidence.

Conclusion: Almost all the studies showed that cerebral edema was associated with severe acidosis and prerenal azotemia in initial DKA presentation and only one case-control study showed a significant correlation with a higher volume of intravenous fluid therapy within the first three hours. The PECARN study put to rest age-long controversy and traditional teaching that aggressive fluid therapy in pediatric DKA may be responsible for cerebral edema with the conclusion that neither rate of fluid administration nor sodium chloride content significantly influenced neurological outcomes in Pediatric DKA