Decline in serum sodium not associated with mental status changes in pediatric diabetic ketoacidosis

by Alexa Fine, Alex Gipsman, MD

Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. In a randomized trial, factors associated with a decline in glucose-corrected sodium in children experiencing diabetic ketoacidosis (DKA) included older age, previous diagnosis of diabetes, higher initial glucose-corrected sodium and chloride concentrations, and treatment with 0.45% sodium chloride

2. There was no association between decline in glucose-corrected sodium concentration and mental status.

Evidence Rating Level: 2 (Good)

Study Rundown:

Previous retrospective studies have shown that decline in serum sodium concentration during treatment of DKA may lead to cerebral edema due to shifts in serum osmolality. This study investigated factors that may be associated with changes in glucose-corrected serum sodium concentration in DKA, and if changes in sodium concentration are associated with mental status changes. Patients were randomized into 1 of 4 intravenous (IV) fluid treatment arms: 0.45% NaCl or 0.9% NaCl infused rapidly or slowly. Mental status was assessed over 4, 8, and 12 hours. Children who were older, previously diagnosed with diabetes, and who presented with higher initial glucose-corrected sodium levels were more likely to experience declines in glucose-corrected sodium concentration across all time points. There were no significant differences in mental status across any treatment arm, and no association was found between mental status changes and serum sodium decline. This study is strengthened by its large cohort size, randomized protocol, and multi-center design. It suggests that although the composition of fluid infusion influences sodium concentration, decline in sodium concentration during DKA treatment is not associated with a risk of cerebral injury.

In-Depth [prospective cohort]:

In this prospective randomized trial, data collected from 13 urban-area emergency departments across the United States for the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in Diabetic Ketoacidosis (FLUID) Trial were analyzed. Children aged 0-18 years of age who were diagnosed with DKA were randomized to 0.45% or 0.9% NaCl solutions infused at a fast (i.e., replace 10% of body weight over 48 hours, with half of the deficit replaced within 24 hours) or slow rate (i.e., replace 5% of body weight evenly over 48 hours). Mental status was assessed using the Glasgow Coma Scale (GCS) hourly, in addition to frequent short-term memory tests. In total, 1251, 1086 and 877 episodes of DKA were included in the 4-,8- and 12-hour analysis, respectively. Factors associated with a decline in glucose-corrected sodium included older age, higher initial sodium and chloride concentrations, previous diagnosis of diabetes, treatment with the 0.45% NaCl arms at all time points, and treatment in the 0.9% NaCl arm at 12 hours. GCS scores, memory function and cerebral injury did not vary significantly across groups.

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