1.1.4.1. Included studies

A total of 1,191 RCTs and systematic reviews and 1,456 observational studies were identified in the search. After removing duplicate references, 677 RCTs and systematic reviews and 861 observational studies were screened at title and abstract stage. 10 additional studies (1 RCT and 9 observational studies) were identified from the 2015 NICE guidance on diabetes (type 1 and type 2) in children and young people: diagnosis and management. Overall, a total of 1,548 studies were screened.

Following title and abstract screening, 30 studies (12 RCTs and systematic reviews and 18 observational studies) were included for full text screening. These studies were reviewed against the inclusion criteria as described in the review protocol (Appendix A). Overall, 12 studies were included (6 RCTs and 6 retrospective cohort studies).

1.1.4.2. Excluded studies

Overall, 18 studies were excluded. See appendix L for list of excluded studies.

Type of fluid - IV fluids

IV+ additives

Rate of rehydration

Volume of rehydration

1.1.7.1. Included studies

334 papers were identified for title and abstract screening, 0 were included for full text screening.

1.1.7.2. Excluded studies

See appendix F for excluded studies list.

IV fluids

IV fluids

1.1.11.1. The outcomes that matter most

The committee highlighted that if DKA is not managed effectively with fluid therapy, cerebral oedema can occur which can lead to mortality. Based on this knowledge, the committee identified outcomes such as incidence of cerebral oedema and mortality as important outcomes.

1.1.11.2. The quality of the evidence

In this review, a combined search was conducted to identify studies which explored route of fluid administration for rehydration, type of fluids (including additives) that should be used for rehydration and the rate and volume these fluids should be administered. Overall, 12 studies (6 RCTs and 6 retrospective cohort studies) were included. Both RCTs and comparative observational studies started as high-quality evidence.

Overall, 7 studies (4 RCTs and 3 retrospective cohort studies) were identified which compared different IV fluids. Evidence from these studies ranged from high to very low quality. Two retrospective cohort studies were identified which compared different additives and the evidence from these studies were of very low quality. Furthermore, 3 studies were identified (2 RCTs and 1 retrospective cohort study) which compared different rates of rehydration and evidence from these studies ranged from high to very low quality. Additionally, 1 RCT was identified which compared different volumes of fluid and evidence from this study was of very low quality. These studies were downgraded through GRADE for risk of bias due to baseline differences in the 2 study arms and for not specifying DKA protocols followed. Studies were also downgraded for indirectness if the DKA protocols followed by the 2 arms of the study were different.

The review protocol specified that studies with a mixed population (children and young people with type 1 and type 2 diabetes) would be included but would be downgraded for indirectness if the data was not reported separately. Overall, 4 studies were identified (Bakes 2016, Glaser 2013, Felner 2001 and Sava-Erdeve 2011) which included participants with type 1 diabetes. The remaining studies included did not explicitly specify the patient characteristics in relation to type of diabetes and did not provide evidence split by the type of diabetes. However, the committee highlighted that DKA is rare in people with type 2 diabetes and management of DKA would not differ based on the type of diabetes. Therefore, studies which did not separate out data by type of diabetes were not downgraded. Furthermore, specific recommendations were not made based on type of diabetes.

Several studies included in the review included participants with all severities of DKA. Among these studies, the PECARN FLUID trial (Kupperman 2018) provided data on confirmed decline in the Glasgow Coma Scale (GCS) score in the whole population as well as in participants who have severe DKA (sample size = 282) which was defined as initial pH of <7.10. Compared to other studies identified in this review, the PECARN FLUID trial was the largest paediatric trial (sample size = 1389) and was considered high quality. While the study did not identify a significant difference in important outcomes in the whole population or in participants with severe DKA, the study did show that both fast and slow fluid protocols followed in the study were safe to use in children and young people with all severities of DKA. Based on this RCT, the committee drafted recommendations that covered all severities of DKA.

Subgroup analysis for different age groups (children under 5, school age children and adolescents) was planned during the review protocol stage. However, evidence was not identified for different age groups. Therefore, no specific recommendations were made based on age.

1.1.11.3. Benefits and harms

The committee noted the current recommendations on route of administration of fluids were ambiguous as in practice IV fluids are preferred in children with DKA. IV fluids can also be switched to oral fluids when the child or young person is alert and not nauseated or vomiting. Based on their clinical understanding, the committee retained the existing recommendation which states that DKA should be treated with intravenous fluids and intravenous insulin if the child or young person is not alert, is nauseated or vomiting or is clinically dehydrated. They also retained an existing recommendation that states that oral fluids should not be given to a child or young person who is receiving IV fluids for DKA unless ketosis is resolving, they are alert and they are not nauseated or vomiting.

The committee also expanded on another existing recommendation and stated that clinicians can think about stopping IV fluid therapy for DKA in a child or young person if ketosis is resolving and blood pH has reached 7.3, they are alert, and they can take oral fluids without nausea or vomiting. The committee further recommended that before stopping intravenous fluid therapy and changing to oral fluids, discussions should take place with the responsible senior paediatrician if the child or young person still has mild acidosis or ketosis. The committee also stated that this should also be dependent on the individual child’s clinical status. It should also be noted that no evidence was identified in the search which compared different routes of administration or different oral fluids for rehydration. Therefore, specific recommendations for oral fluids were not made.

When reviewing the evidence for type of fluids for rehydration, the committee noted that the evidence did not favour any of the interventions. While there were some significant results, evidence for the critical outcomes (cerebral oedema and mortality) did not favour an IV fluid for rehydration. A similar trend was also observed with evidence for rate, and volume of rehydration.

The committee noted that both fluid protocols followed in the PECARN FLUID trial were safe to use as the study did not identify a significant difference in mortality or clinically apparent brain injury. While the pathogenesis of cerebral oedema is not completely understood, the study highlighted that cerebral oedema is a feature of clinically apparent brain injury and often develops hours or days after diagnosis of brain injury. This finding suggests that cerebral oedema may be a consequence rather than a cause of brain injury. The committee further noted that the trial highlighted that restrictions to fluid administration as advised in the 2015 guideline were not necessarily required.

In line with the evidence identified from the PECARN FLUID trial and applying their clinical expertise, the committee recommended that for children and young people who are clinically dehydrated but not in shock, an initial bolus of 10ml/kg of 0.9% sodium chloride should be given over 30 minutes. This is also in line with the International Society for Paediatric and Adolescent Diabetes (ISPAD) guideline which states that resuscitation fluids should be administered over 30 to 60 minutes and if tissue perfusion is poor then initial fluid bolus should be given more rapidly, for example, over 15 to 30 minutes.

The committee further recommended that before giving more than one IV fluid bolus of 10 ml/kg 0.9% sodium chloride, it should be discussed with the responsible senior paediatrician. Additionally, a second bolus may be considered to improve tissue perfusion after reassessing their of clinical status. Separate recommendations were also developed for children and young people who present with shock.

The committee also highlighted that separate recommendations were necessary for children and young people with signs of shock. Recommendations developed in 2015 stated that IV bolus should not be given to children and young people with mild or moderate DKA and should not be routinely given to children and young people with severe DKA. The rationale provided for these recommendations further stated that fluid bolus should be avoided unless there are signs of shock associated with poor urine output or hypotension.

The committee noted that while shock is a rare occurrence in children and young people with DKA, it can occur, and such patients require more fluid boluses to improve tissue perfusion. Furthermore, the committee highlighted that restricting initial fluid boluses can result in less fluids being administered over the 48-hour period. The committee stated that this may be problematic as recent hypothesis and data suggests that brain injury may result from cerebral hypoperfusion and the effects of reperfusion and neuro-inflammation that occurs during episodes of DKA. The committee highlighted that the 2015 recommendations could have been made with the risk of cerebral oedema in mind as the previous hypothesis stated that rapid administration of IV fluids reduces serum osmolality which results in brain swelling.

Based on their clinical judgment and the RCT evidence identified in the review, particularly the PECARN FLUID trial, the committee recommended that in children and young people with DKA who have signs of shock, an initial intravenous bolus of 20 ml/kg 0.9% sodium chloride should be given as soon as possible. The committee also noted that shock may be misclassified in children and young people with moderate to severe DKA. Therefore, the committee further recommended that prolonged capillary refill, tachycardia and tachypnoea are common in children with moderate to severe DKA, but this does not mean the child or young person is in shock because these are signs of vasoconstriction caused by metabolic acidosis and hypocapnia.

The committee further highlighted that assessment of dehydration is generally poor in children and young people with DKA and the current recommendations on calculating total fluid requirement can result in less fluid being given over the 48-hour period. Based on RCT evidence identified in this review, particularly the PECARN FLUID trial, the committee retained recommendations on calculating the fluid deficit and stated that in children and young people with mild to moderate DKA, 5% dehydration should be assumed. This means that a child weighing 10kg who is 5% dehydrated would have a water deficit of 500mls. Furthermore, 10% dehydration should be assumed in children and young people with severe DKA.

The committee also highlighted that critically ill children are at a higher risk of cerebral oedema. Due to this more caution is needed when calculating fluid requirement. As the PECARN Fluid trial did not fully capture critically ill children, the committee used their expertise to recommend that the aim should be to replace the fluid deficit evenly over the first 48 hours, but in critically ill children and young people, the fluid regimen should be discussed early with the senior paediatrician or paediatric intensivist (or both), because the risk of cerebral oedema is higher. The committee further noted that it is crucial that treatment is not delayed due to the risk of cerebral oedema.

The recommendation for calculating fluid maintenance requirement was amended to include the Holliday-Segar formula. The committee noted that this formula has been shown to be safe with no adverse events and is commonly used in practice. The International Society for Paediatric and Adolescent Diabetes (ISPAD) guideline and the British Society of Paediatric Endocrinology and Diabetes (BSPED) guideline also recommend the use of this formula when calculating maintenance requirement. Additionally, the Holliday-Segar formula was also used in the PECARN FLUID trial. The committee also further stated that when calculating the total fluid requirement, any initial bolus volumes given should be subtracted from the total fluid deficit, except in children who are in shock.

The committee noted that the new recommendations will provide a more balanced approach for calculating the total fluid requirement. However, the committee did highlight that caution must be taken when calculating the fluid requirement for children and young people who are obese. Based on their clinical understanding, the committee agreed that a maximum weight of 75kg should be used in calculating fluid requirement for children and young people who are obese as this is approaching fluid requirements of adults with DKA. This will avoid excessive fluid administration and minimise risks in children and young people who are obese.

No evidence was identified for the use of potassium in the management of DKA. However, the committee highlighted that children and young people with DKA can develop hypokalaemia which occurs when there is a significant depletion of potassium in the body. Based on their clinical expertise and their understanding of the evidence on the pathophysiology of DKA the committee retained the existing recommendation but expanded it to state that 40 mmol/litre potassium chloride (or 20 mmol/500ml) should be added in all fluids (except the initial intravenous boluses) unless the child or young person with DKA has anuria or their potassium level is above the normal range. The committee also cautioned that potassium replacement should not be delayed because hypokalaemia can occur once insulin infusion begins.

The committee further highlighted that the administration of insulin and correction of acidosis, drives potassium into the cells and can lead to a fall in potassium levels. This is a major concern as this can cause cardiac arrhythmias and mortality. This means that treatment should not be delayed in children and young people with potassium levels above normal range.

Based on their clinical understanding, the committee recommended that in this population, potassium should only be added if the potassium level is less than 5.5 mmol/litre or they have passed urine, which gives the assurances that the child or young person does not have renal failure. They also recommended that for children and young people with DKA who have hypovolaemia at presentation, include potassium chloride in intravenous fluids before starting the insulin infusion.

Hypoglycaemia is another complication that can occur in children and young people with DKA. No evidence was identified in the search for the addition of glucose to IV fluids. Therefore, the committee retained the current recommendations which state that 0.9% sodium chloride should be used without added glucose for both rehydration and maintenance fluid until the plasma glucose concentration is below 14 mmol/ litre. When the glucose concentration falls below 14 mmol/litre, fluids should be changed to 0.9% sodium chloride with 5% glucose and 40mmol/litre potassium chloride.

Serum chloride concentration was included as an outcome in the review protocol. Only two studies were identified which explore this outcome. Shafi 2018 highlighted that chloride concentration was significantly lower in participants who received 0.9% saline compared to those who received hypertonic saline. Yung 2017 could not differentiate the maximum chloride concentration between participants who received 0.9% saline and those who received Hartmann’s solution.

The committee further highlighted that children and young people with DKA can develop hyperchloremic acidosis which is defined as a persisting base deficit or low bicarbonate concentration despite evidence of resolving ketosis and clinical improvement. Based on this, the committee drafted a recommendation alerting clinicians of this condition and stating that this should resolve spontaneously over time and does not require any specific management.

Additionally, serum sodium concentration was also an outcome included in the review protocol. Several studies were identified which examined sodium concentration but only one study (Basnet 2014) found that the change in corrected sodium was significantly higher with 0.9% saline compared to 0.45% saline. The committee noted that it was important to ensure that clinicians are monitoring serum sodium levels as some children and young people may be hyponatraemic, which occurs when sodium levels are low.

Based on this knowledge, the committee drafted recommendations to state that sodium levels should be monitored throughout the course of therapy and to calculate the corrected sodium initially to identify if the patient is hyponatraemic. When monitoring serum chloride levels, be aware that serum sodium should rise as DKA is treated as blood glucose falls and a falling serum sodium is a risk factor for cerebral oedema. The committee further recommended that a rapid and ongoing rise in serum sodium concentration may also suggest possible cerebral oedema, caused by the loss of free water in the urine. The committee drafted these recommendations to further support the recommendations in the ‘monitoring during therapy’ section of the guideline.

Limited evidence was identified which examined the effectiveness of adding sodium bicarbonate compared to no sodium bicarbonate. However, the evidence did not favour the use of sodium bicarbonate as an additive to IV fluids. Based on this evidence and their clinical understanding the committee agreed that sodium bicarbonate should not be routinely used. The committee also further highlighted a small number of children and young people with DKA can exhibit compromised cardiac contractility caused by life-threatening hyperkalaemia or severe acidosis. Such seriously ill children and young people can benefit from intravenous sodium bicarbonate. Based on this understanding, the committee expanded on the current recommendation to state that intravenous sodium bicarbonate should not be given to children and young people with DKA unless their cardiac contractility has been compromised by life-threatening hyperkalaemia or severe acidosis. The committee also agreed that before starting treatment, the decision should be discussed with the paediatric intensivist.

1.1.11.4. Cost effectiveness and resource use

No economic evidence was identified for this review question. The committee noted that new recommendations are in line with current practice and therefore should result in negligible cost differences. As the costs and consequences of adverse effects are severe, cost-effectiveness is driven by treatment effectiveness.

1.1.11.5. Other factors the committee took into account

The fluid protocol highlighted in the recommendations were based on RCT evidence that was identified in the search, however, the committee are aware that in some paediatric units, PlasmaLyte 148 is being used for initial resuscitation. Compared to 0.9% sodium chloride, PlasmaLyte 148 has a lower sodium and chloride content compared to 0.9% sodium chloride. It has been suggested that due to is formulation, hyperchloremic acidosis is less likely to occur.

Only one small study with only 64 partiipants (William 2020) was identified which compared PlasmaLyte (study refers to the fluid as PlasmaLyte-A) to 0.9% normal saline as initial fluid in the management of DKA in children. However, the study could not differentiate between the two fluids in outcomes such as incidence of acute kidney injury, mortality, and cerebral oedema. The committee also noted that the rates of complications identified in the study were higher than would normally be seen in NHS settings as this study was conducted in a low-middle income country.

Based on the findings of this study, the committee were unable to recommend for the use of PlasmaLyte 148 but highlighted that further research is needed to explore the effectiveness of PlasmaLyte 148 as a resuscitation fluid in the management of DKA in children and young people with diabetes. Therefore, the committee drafted a research recommendation.

The committee removed a recommendation which states that clinicians may consider inserting a urinary catheter if it is not possible to accurately measure urine output for a child or young person with DKA. While the committee agreed it was important to monitor patients, urinary catheterisation is not a commonly used in practice but may be adopted in an intensive care scenario when managing a seriously ill child or young person with DKA. As this is general guidance, the committee did not think a recommendation on urinary catheterisation was within the remit of this guideline.

The committee also highlighted that no prospective audits have been established to monitor change in practice after the 2015 DKA recommendations were produced. The committee agreed that it was important to assess the implementation of these updated recommendations in practice. As there is not an existing audit, the committee could not make any research recommendations but agreed that an audit of practice would be valuable.

Finally, the committee identified the following equality issues:

• Age – children under the age of five have a greater risk of DKA
• Race – Black and minority ethnic children present to hospital with DKA more frequently
• Sex - girls and young women are more likely to develop DKA
• Socio-economic factors - Children and young people in the most deprived areas of the UK are more likely to be hospitalised for DKA

The committee considered these equality issues but were of the opinion that these did not directly impact on fluid therapy for the management of DKA in children and young people. These equality issues would not influence the optimal route of fluid administration, type of fluid (including additives) or the rate and volume for rehydration in children and young people with DKA.

1.1.13.1. Effectiveness

1.1.13.2. Economic

None

1.1.13.3. Other

None

Quality assessment

Individual RCTs were quality assessed using the Cochrane Risk of Bias Tool 2.0. Cohort studies were quality assessed using the ROBINS-I tool. Each individual study was classified into one of the following groups:

• Low risk of bias – The true effect size for the study is likely to be close to the estimated effect size.
• Moderate risk of bias – There is a possibility the true effect size for the study is substantially different to the estimated effect size.
• High risk of bias – It is likely the true effect size for the study is substantially different to the estimated effect size.
• Critical risk of bias (ROBINS-I only) - It is very likely the true effect size for the study is substantially different to the estimated effect size.

Each individual study was also classified into one of three groups for directness, based on if there were concerns about the population, intervention, comparator and/or outcomes in the study and how directly these variables could address the specified review question. Studies were rated as follows:

• Direct – No important deviations from the protocol in population, intervention, comparator and/or outcomes.
• Partially indirect – Important deviations from the protocol in one of the following areas: population, intervention, comparator and/or outcomes.
• Indirect – Important deviations from the protocol in at least two of the following areas: population, intervention, comparator and/or outcomes.

Methods for combining intervention evidence

Meta-analyses of interventional data were conducted with reference to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins et al. 2011).

Where different studies presented continuous data measuring the same outcome but using different numerical scales (e.g. a 0-10 and a 0-100 visual analogue scale), these outcomes were all converted to the same scale before meta-analysis was conducted on the mean differences. Where outcomes measured the same underlying construct but used different instruments/metrics, data were analysed using standardised mean differences (Hedges’ g).

A pooled relative risk was calculated for dichotomous outcomes (using the Mantel–Haenszel method) reporting numbers of people having an event, and a pooled incidence rate ratio was calculated for dichotomous outcomes reporting total numbers of events. Both relative and absolute risks were presented, with absolute risks calculated by applying the relative risk to the risk in the comparator arm of the meta-analysis (calculated as the total number events in the comparator arms of studies in the meta-analysis divided by the total number of participants in the comparator arms of studies in the meta-analysis).

Fixed- and random-effects models (der Simonian and Laird) were fitted for all syntheses, with the presented analysis dependent on the degree of heterogeneity in the assembled evidence. Fixed-effects models were the preferred choice to report, but in situations where the assumption of a shared mean for fixed-effects model were clearly not met, even after appropriate pre-specified subgroup analyses were conducted, random-effects results are presented. Fixed-effects models were deemed to be inappropriate if one or both of the following conditions was met:

• Significant between study heterogeneity in methodology, population, intervention or comparator was identified by the reviewer in advance of data analysis. This decision was made and recorded before any data analysis was undertaken.
• The presence of significant statistical heterogeneity in the meta-analysis, defined as I²≥50%.

However, in cases where the results from individual pre-specified subgroup analyses are less heterogeneous (with I² < 50%) the results from these subgroups will be reported using fixed effects models. This may lead to situations where pooled results are reported from random-effects models and subgroup results are reported from fixed-effects models.

In situations where subgroup analyses were conducted, pooled results and results for the individual subgroups are reported when there was evidence of between group heterogeneity, defined as a statistically significant test for subgroup interactions (at the 95% confidence level). Where no such evidence as identified, only pooled results are presented.

In any meta-analyses where some (but not all) of the data came from studies at critical or high risk of bias, a sensitivity analysis was conducted, excluding those studies from the analysis. Results from both the full and restricted meta-analyses are reported. Similarly, in any meta-analyses where some (but not all) of the data came from indirect studies, a sensitivity analysis was conducted, excluding those studies from the analysis.

Meta-analyses were performed in Cochrane Review Manager V5.3, with the exception of incidence rate ratio analyses which were carried out in R version 3.3.4.

Minimal clinically important differences (MIDs)

The Core Outcome Measures in Effectiveness Trials (COMET) database was searched to identify published minimal clinically important difference thresholds relevant to this guideline. Identified MIDs were assessed to ensure they had been developed and validated in a methodologically rigorous way, and were applicable to the populations, interventions and outcomes specified in this guideline.

In addition, the Guideline Committee were asked to prospectively specify any outcomes where they felt a consensus MID could be defined from their experience. In particular, any questions looking to evaluate non-inferiority (that one treatment is not meaningfully worse than another) required an MID to be defined to act as a non-inferiority margin.

No MIDs were identified through this process. Therefore, for continuous outcomes expressed as a mean difference where no other MID was available, an MID of 0.5 of the median standard deviations of the comparison group arms was used (Norman et al. 2003). For continuous outcomes expressed as a standardised mean difference where no other MID was available, an MID of 0.5 was used. For relative risks and hazard ratios, where no other MID was available, the line of no effect was used.

When decisions were made in situations where MIDs were not available, the ‘Evidence to Recommendations’ section of that review makes explicit the committee’s view of the expected clinical importance and relevance of the findings. In particular, this includes consideration of whether the whole effect of a treatment (which may be felt across multiple independent outcome domains) would be likely to be clinically meaningful, rather than simply whether each individual sub outcome might be meaningful in isolation.

GRADE for pairwise meta-analyses of interventional evidence

GRADE was used to assess the quality of evidence for the selected outcomes as specified in ‘Developing NICE guidelines: the manual (2014)’. Data from randomised controlled trials, non-randomised controlled trials and comparative observational studies were initially rated as high quality.. The quality of the evidence for each outcome was downgraded or not from this initial point, based on the criteria given in Table 1.

Table 1. Rationale for downgrading quality of evidence for intervention studies

Summary of evidence is presented in section 1.1.6. This summarises the effect size, quality of evidence and interpretation of the evidence in relation to the significance of the data.

Evidence was also identified for which GRADE could not be applied as the evidence was presented in the form of median and interquartile range. This evidence is presented in Appendix G. This evidence has been summarised narratively in section 1.1.10.

RCTs

Shafi 2018 (PDF, 188K)

Williams 2020 (PDF, 192K)

Yung 2017 (PDF, 188K)

Observational studies

Basnet 2014 (PDF, 176K)

Bergmann 2018 (PDF, 178K)

Savaş-Erdeve 2011 (PDF, 186K)

RCTs

Kuppermann 2018 (PDF, 205K)

Observational studies

Green 1998 (PDF, 187K)

Mar 1981 (PDF, 176K)

RCTs

Glaser 2013 (PDF, 186K)

Observational studies

Felner 2001 (PDF, 188K)

RCTs

Bakes 2016 (PDF, 186K)

Moderate to severe DKA

All severities of DKA

Type 1 diabetes - All severities of DKA

Severe DKA

All severities of DKA

All severities of DKA

Type 1 diabetes- All severities of DKA

Type 1 diabetes- All severities of DKA

Moderate to severe DKA

0.9% Saline vs Hypertonic saline (3% NaCl) as initial IV fluid

0.9% Saline vs Plasma-Lyte-A as initial IV fluid

0.9% Saline vs 0.45% saline for replacement of deficit

Normal saline vs Ringer’s lactate

All severities of DKA

Moderate to severe DKA

0.9% Saline vs Plasma-Lyte-A as initial IV fluid

Outcomes during 24 hours of treatment

Outcomes during 48 hours of treatment

Outcomes till discharge

0.9% Saline vs 0.45% saline for replacement of deficit

Outcomes during treatment of DKA

Outcomes 2 to 6 months after hospitalisation

0.9% Saline vs 0.45% saline post-bolus re-hydration fluid

Outcomes during treatment of DKA

Normal saline vs Ringer’s lactate

Outcomes during treatment of DKA

75 mEq/L NaCl vs 100 mEq/L NaCl after initial rehydration

Outcomes during 1 hour of treatment

Outcomes during 24 hours treatment

Severe DKA

All severities of DKA

All severities of DKA

Type 1 diabetes- All severities of DKA

Type 1 diabetes- All severities of DKA

Why this is important

Based on the available evidence, the committee recommended the use of 0.9% sodium chloride as resuscitation fluid in the management of DKA. However, the committee were aware that some paediatric units are using PlasmaLyte 148 for initial resuscitation. PlasmaLyte 148 has a lower sodium and chloride content compared to 0.9% sodium chloride and because of this, it is suggested that hyperchloremic acidosis is less likely to occur. However, research is required to demonstrate the effectiveness of PlasmaLyte 148 as resuscitation fluid in the management of DKA in children and young people.

Rationale for research recommendation

Only one study was identified which compared PlasmaLyte (study refers to fluid as PlasmaLyte-A) with 0.9% normal saline as initial fluid in the management of DKA in children. This study could not differentiate between the two fluids in outcomes such as incidence of acute kidney injury, mortality, and cerebral oedema. Due to the lack of evidence, the committee were unable to make recommendations but noted that further robust research is required to ascertain the effectiveness of PlasmaLyte 148 as resuscitation fluid in the management of DKA in children and young people.

Modified PICO table