Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial

J Emerg Med. 2016 Apr;50(4):551-9. doi: 10.1016/j.jemermed.2015.12.003. Epub 2016 Jan 25.


Background: The optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown.

Objective: Our aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization.

Methods: We performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each).

Results: After adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0-3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2-5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6-2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4-1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4-1.5; p = 0.5) did not differ between treatment groups.

Conclusions: Higher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.

Keywords: DKA; acidosis; bicarbonate; fluid resuscitation; ketoacidosis; ketones; pediatric diabetes.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adolescent
  • Bicarbonates / therapeutic use
  • Biomarkers / blood
  • Child
  • Diabetic Ketoacidosis / therapy*
  • Emergency Service, Hospital
  • Female
  • Fluid Therapy / methods*
  • Humans
  • Length of Stay / statistics & numerical data
  • Male
  • Treatment Outcome


  • Bicarbonates
  • Biomarkers

Associated data

  • ClinicalTrials.gov/NCT01701557