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Fluid management during diabetic ketoacidosis in children: guidelines, consensus, recommendations and clinical judgement
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  1. Robert Charles Tasker1,2
  1. 1 Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  2. 2 Selwyn College, University of Cambridge, Cambridge, UK
  1. Correspondence to Professor Robert Charles Tasker, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; robert.tasker{at}childrens.harvard.edu

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Two letters in the journal focus on the volume of intravenous fluid to be used during resuscitation and early management of paediatric patients presenting with diabetic ketoacidosis (DKA).1 2 The correspondence encapsulates an important debate about intravenous fluids and risk of morbidities, such as cerebral oedema, and provides us with the range in contemporary opinions in the UK.

Lillie et al 1 use their insights from the South Thames Retrieval service (STRS) and its 20 referring district general hospitals to highlight a concern about the new British Society for Paediatric Endocrinology and Diabetes (BSPED) guideline3 and integrated care pathway4 for the management of DKA. The authors have a network of emergency practice, and they imply that the new emphasis by the BSPED on permissive rather than restrictive (ie, reduced volume rules) intravenous fluids will be disruptive to the measures that they have taken since dealing with three cerebral oedema deaths in their region. Wright and Thomas2 have responded on behalf of the BSPED DKA interest group. They emphasise the importance of adequate intravenous fluid resuscitation in limiting morbidity. They also provide an instructive table2 showing fluid resuscitation and rehydration volumes used in a number of protocols, including that of STRS and the new BSPED approach. The main differences come down to the estimate of fluid deficit, the use of an intravenous fluid bolus at presentation and the calculation of maintenance fluid requirements.

The STRS approach assumes a 10% …

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