P2.111: Lower Rates of Hyperchloremia in Pediatric Diabetic Ketoacidosis Treated with Hypotonic Compared to Isotonic Fluids

Background: Diabetic ketoacidosis (DKA) is a common and life-threatening complication of type 1 diabetes mellitus. Fluid resuscitation is an integral component of DKA management, however, there is no consensus on the optimal fluid choice in pediatric patients. Normal saline (0.9% NaCl) has been the common fluid of choice, but recent evidence suggests that the high chloride content increases the risk of hyperchloremia with metabolic acidosis and acute kidney injury (AKI). A recent multi-center trial found hypotonic saline (0.45% NS) to be safe for use in pediatric DKA patients, without increased incidence of cerebral edema. Given this emerging evidence, we modified the two-bag intravenous fluid system used for the management of DKA in our pediatric ICU (PICU). Initially, the first bag was 0.9% NS and the second bag was 0.9% NS with dextrose, which is used as the patients’ blood glucose levels improve. In an effort to reduce the chloride load, the base fluid in bag 2 was changed to 0.45% saline with dextrose. The objective of this study is to investigate the effect of hypotonic fluid on clinical outcomes in pediatric DKA.

Methods: This is a single-center retrospective cohort analysis of 169 patients aged 0 to 19 years who were admitted to our PICU with DKA between October 1, 2017 and February 26, 2024. The significance of associations between cohorts was measured using t-tests and chi-squared tests.

Results: All patients received 0.9% NS in bag 1, while cohort 1 also received 0.9% NS in bag 2 (N=99) and cohort 2 received 0.45% NS in bag 2 (N=70). There was a trend toward a significant difference in the incidence of hyperchloremia, which occurred in 70% of patients in cohort 1 and 52% of patients in cohort 2 (p=0.054). Hypernatremia occurred in 27% of patients in cohort 1 and 25% in cohort 2 (p=0.967). Mannitol was administered to one patient in each cohort, indicating no difference in rates of symptomatic cerebral edema between cohorts. Time to resolution of DKA was not significantly different between the two groups, as measured by time to anion gap closure and resolution of acidosis.

Conclusion: During treatment of pediatric DKA, administration of 0.45% NS in bag 2 may reduce the incidence of hyperchloremia, which has been shown to be associated with AKI in children. This suggests that using hypotonic saline as part of a fluid regimen may protect patients’ kidneys, which are already at increased risk for damage due to hyperglycemia. There was no significant effect on symptomatic cerebral edema, which supports that the use of hypotonic saline may be safe for pediatric patients with DKA. Further research is needed to examine whether use of hypotonic saline significantly affects clinical outcomes, particularly AKI and development of long-term kidney disease.