Evidence-based emergency medicine/critically appraised topic. Is fluid therapy associated with cerebral edema in children with diabetic ketoacidosis?

STUDY OBJECTIVE: Diabetic ketoacidosis is the most common cause of morbidity and mortality in children with type I diabetes mellitus, and cerebral edema is the leading cause of pediatric diabetic ketoacidosis death. Excessive intravenous fluid administration has been implicated as a cause of cerebral edema. We perform an evidence-based emergency medicine review assessing the association of intravenous fluid hydration and cerebral edema.

METHODS: We searched MEDLINE and EMBASE for comparative studies. Because of the low incidence of cerebral edema, we included observational studies in our review. We sought studies including patients younger than 18 years and with diabetic ketoacidosis. We defined cerebral edema, using clinical, radiographic, pathologic criteria, or treatment for intracranial pressure.

RESULTS: Three studies met criteria for this review, of which 2 used fluid volume/body weight per unit of time, and the third measured cumulative total volume during hourly periods. The first 2 studies showed no statistically significant association between intravenous fluid administration and cerebral edema. The third study showed a significant association (odds ratio 6.55; 95% confidence interval 1.38 to 30.97) between the total volume (uncorrected for body weight) of infused fluid and the risk of cerebral edema.

CONCLUSION: Accepting the inherent limitations of observational studies, we found a lack of strong or consistent results implicating rate or volume of fluid administration as a precipitant cause of cerebral edema in patients with diabetic ketoacidosis.