Management Of Pediatric Diabetic Ketoacidosis: Does Aggressive Fluid Resuscitation Actually Result In Cerebral Edema? The Case Of A 6-Year-Old With Aggressive Fluid Resuscitation

ABSTRACT Objective: The role of fluid resuscitation in the causation of cerebral edema has been controversial and the subject of several studies over the decades. The aim of this case report is to challenge the perception that aggressive fluid resuscitation in pediatric diabetic ketoacidosis (DKA) causes cerebral edema. Methods: We describe the case of a 6-year-old with DKA who made an excellent recovery with no immediate or long-term sequelae, despite being given large amounts of appropriate fluids for resuscitation. Additional literature review was conducted to explore the link between DKA and fluid resuscitation. Results: Many Canadian and international experts recommend initial fluid resuscitation with intravenous normal saline at 10 to 20 mL/kg within the first 1 to 2 hours to a maximum of 30 mL/kg only if shock is suspected. Our patient required in excess of 30 mL/kg as recommended and was transferred to a regional pediatric intensive care unit, where the aggressive volume expansion was continued, and made an excellent recovery. Conclusion: The apprehension towards a more liberal resuscitation is due to the feared theoretical risk, which has not been borne by the available evidence. Despite this absence of evidence, several international recommendations have remained conservative in their approach. A more aggressive approach in certain situations may be appropriate as recommended by the new International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines. Abbreviations: CT = computed tomography; DKA = diabetic ketoacidosis; IV = intravenous; NS = normal saline; PICU = pediatric intensive care unit