Treating Childhood Diabetic Ketoacidosis With Fluids May Not Cause Brain Injury

Highlights:

• New study shows that intravenous (IV) fluids may not be causing brain damage in children with diabetic ketoacidosis (DKA) as is popularly believed
• Currently held belief is that IV fluids may be harmful in children with DKA and consequently clinicians tend to restrict IV infusion therapy in these patients
• Children with DKA, especially if dehydrated can be administered IV fluids without fear, instead of withholding fluidsa

Administering IV fluids in children with diabetic ketoacidosis may not be causing injury as is currently believed, according to a recent study conducted by scientists at UC Davis and collaborators from across the US. The first author of this study is Nathan Kuppermann, distinguished professor and chair of emergency medicine, and his wife and research partner Nicole Glaser is professor of pediatrics and senior author of the paper who started working on this problem almost two decades earlier.

The findings of the study appear in the reputed journal New England Journal of Medicine (NEJM).

Aim of Study - Questioning Currently Held Beliefs In Children With DKA

Following an observation by doctors in the 1980s, that children admitted with DKA who developed brain swelling seemed to have received more IV fluids, it came to be believed that the IV fluids were causing the brain damage.

The authors of the study feel that these previous studies in children with DKA might not have taken into adequate consideration the seriousness of the child's initial condition at presentation when assessing the influence of IV fluid therapy in causing brain swelling and damage.

"The severity of dehydration in the child is strongly linked to the risk of brain injury," said Glaser, professor of pediatrics and senior author on the paper. "Of course, kids who are more dehydrated, receive more fluids. You can erroneously make the conclusion that fluids are causing the brain swelling, when it's just a reflection of the fact that children who are sickest and have the greatest dehydration are the ones at greatest risk."

Details of Current Study

The study was undertaken at 13 centers over a period of six years as part of the nationwide Pediatric Emergency Care Applied Research Network (PECARN) initiative.

• The authors assessed how intravenous fluid administration and certain other factors affected neurological outcome in 1389 children with DKA
• The patients were divided into four groups based on rate of infusion and saline content of the IV fluids
• Children who had more rapid infusion of fluids showed a reduced incidence of brain damage but the results were not significant statistically
• In a small group of children, who were most sick i.e most acidotic (when body fluids contain too much acid), rapid IV infusion was found to be associated with significant improvement in brain function

Overall, the study did not show any statistically significant difference between the various groups of patients.

Says Nathan Kuppermann, "For three decades, we have been giving children too little fluids because we've been taught that fluids cause brain injuries in children with DKA. It's not about the fluid, it's about something else. It's time we started looking beyond fluids and addressing the other factors that are important."

The authors hasten to add that the findings of their study do not mean that IV fluids can be given inappropriately in all DKA children. However, in children with dehydration, fluids need not be restricted and can be given without fear (of complications).

Earlier Research on the Same Problem by Kuppermann and Glaser

Kuppermann and his team had earlier conducted a study on the same subject that appeared in the NEJM in 2001. They showed that it was unlikely that the IV fluids were causing brain damage in DKA children. However, as the study was not a prospective randomized controlled trial, (considered the gold standard in medical research), the findings of the study did not bring about the desired change in fluid management guidelines in DKA children, perhaps prompting the current study.

What is Diabetic Ketoacidosis (DKA)?

Diabetic Ketoacidosis (DKA)is a potentially serious complication of diabetes that could be fatal if not managed urgently. In this condition, the body is unable to metabolize sugar (due to insulin deficiency) and starts breaking down fatty acids to provide energy with formation of ketones resulting in DKA.

Occurrence of brain swelling is associated with a poor prognosis and increased mortality. The condition has to be promptly recognized and managed. Major and minor criteria are in place for improved diagnosis and treatment.

Future Plans

• The team hopes to build on the earlier studies that have shown an association between abnormal blood flow to the brain and inflammatory proteins and brain damage to further delineate the mechanisms of brain injury and damage in DKA children

According to Glaser, future studies may shift the focus from fluids and explore the role of anti-inflammatory drugs to protect and prevent brain damage.

Reference:

1. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis - (https://www.nejm.org/doi/full/10.1056/NEJMoa1716816)

Source-Medindia