Management of fluids in paediatric diabetic ketoacidosis: concerns over new guidance

In January 2020, the British Society for Paediatric Endocrinology and Diabetes (BSPED) published new guidance for the management of children <18 years with diabetic ketoacidosis (DKA).1 Fluid management is significantly different from their previous guideline2 and current National Institute for Health and Care Excellence (NICE) guidance.3 The 2020 guideline moved away from the concept of cautious fluid replacement towards a liberal approach for resuscitation and maintenance fluids. It recommends that all patients receive an initial 10 mL/kg bolus and those presenting with shock receive a 20 mL/kg bolus. Concerningly, delayed capillary refill time is used to define shock; however, in DKA this sign is confounded by hypocapnoeic vasoconstriction, which is common.4 A 20 mL/kg fluid bolus is also recommended for ‘reduced conscious level/coma’, without considering that this may indicate cerebral oedema which can be aggravated by additional fluid administration. Junior staff are enabled to give boluses of up to 40 mL/kg, contrasting starkly …