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Management of fluids in paediatric diabetic ketoacidosis: concerns over new guidance
  1. Jon Lillie1,
  2. Elizabeth Boot2,
  3. Shane M Tibby1,
  4. Marilyn McDougall1,
  5. Andrew Nyman1,
  6. Benedict Griffiths1,
  7. Miriam Fine-Goulden1,
  8. Maja Pavcnik1,
  9. Ariane Annicq1,
  10. Shelley Riphagen1
  1. 1 South Thames Retreival Service and Paediatric Intensive Care, Evelina London Children's Hospital, London, UK
  2. 2 Paediatrics, Epsom and St Helier Hospital NHS Trust, Carshalton, Sutton, UK
  1. Correspondence to Dr Jon Lillie, Paediatric Intensive Care, Evelina London Children's Hospital, London SE1 7EH, UK; Jonathan.Lillie{at}

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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 …

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  • Twitter @DrJonLillie, @docmcdevelina, @finegoulden

  • Contributors All authors contributed to the acquisition of DKA data for the South Thames Retrieval Service. All authors were involved in drafting or revising the letter and have given approval for this final submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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