Rationale and impact

Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice.

Fluid therapy

Recommendations 1.4.21 to 1.4.34, 1.4.39, 1.4.40 and 1.4.42.

Why the committee made the recommendations

Route of fluid administration

The 2015 recommendations caused some confusion around when to use oral or intravenous fluids. To address this, the committee looked for research evidence that would help them to make clearer recommendations. There was no evidence that compared different routes of administration or different oral fluids for hydration, so the committee updated the recommendations based on their experience and expertise.

Rate of fluid administration

In the 2015 guideline, the rate of fluid administration in diabetic ketoacidosis (DKA) was restricted because rapid fluid administration was believed to cause cerebral oedema. However, for the 2020 update there was some randomised controlled trial evidence (particularly the PECARN FLUID trial) comparing the effect of different DKA protocols on outcomes such as mortality or clinically apparent brain injury. This evidence showed no significant difference between the 2 protocols, and it demonstrated that the restrictions on the rate of fluid administration were not needed.

In response to this evidence, and applying their clinical expertise, the committee updated the recommendations to use more rapid fluid administration (including fluid boluses). They also made a separate recommendation for children and young people who are in shock, as this group need a higher volume of fluids, and they need these fluids to be given more rapidly.

Total fluid requirement

When the 2015 recommendations were made, rapid fluid administration was believed to cause cerebral oedema. However, more recent randomised controlled trial evidence (particularly the PECARN FLUID trial) has shown that brain injury in this group may be caused by DKA itself, because of the resulting cerebral hypoperfusion, reperfusion and neuro-inflammation. If DKA is the cause of brain injury, children and young people would benefit from receiving more fluids in the first 48 hours than was recommended in the 2015 guideline. To address this, the committee updated the recommendation on calculating the fluid maintenance requirement, based on their clinical knowledge and on evidence from the PECARN FLUID trial. The Holliday-Segar formula that they recommended is commonly used in practice and has not been shown to cause any adverse events.

Potassium

No evidence was identified on the use of potassium. The committee used their expertise and their understanding of the evidence on the pathophysiology of DKA to update the recommendation. They added more detail about how to care for children and young people with anuria or potassium levels above the normal range. It is essential to not delay adding potassium to fluids, because insulin can cause hypokalaemia in this population, which can lead to cardiac arrhythmias and death.

Hyperchloremic acidosis

The committee also used their expertise to make recommendations highlighting complications such as hyperchloremic acidosis.

Hyponatraemia

The committee used their expertise to make recommendations on monitoring serum sodium levels and identifying children and young people with hyponatreameia.

How the recommendations might affect practice

There is variation in practice due to the different beliefs on the causes of cerebral oedema. The new recommendations will be a change in practice in some areas, but they are in line with randomised trial evidence and with other clinical guidance (such as the International Society for Paediatric and Adolescent Diabetes DKA guideline).

Return to recommendations

  • National Institute for Health and Care Excellence (NICE)