Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis.

Julie K McManemy, Nathan Kuppermann, Simona Ghetti, T Charles Casper, Cody S Olsen, Jeff E Schunk, Leah Tzimenatos, Lise E Nigrovic, Andrew D DePiero, Nicole S Glaser, Kimberly S Quayle, Jennifer L Trainor, Kathleen M Brown, Arleta Rewers, Sage R Myers, Scott Baird, Aris Garro, Michael J Stoner

Journal: Pediatrics 2021;148(3):e2021050243

PMID: 34373322

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Abstract

OBJECTIVES

Diabetic ketoacidosis (DKA) is typically characterized by low or low-normal serum sodium concentrations, which rise as hyperglycemia resolves. In retrospective studies, researchers found associations between declines in sodium concentrations during DKA and cerebral injury. We prospectively investigated determinants of sodium concentration changes and associations with mental status alterations during DKA.

METHODS

Using data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis Trial, we compared children who had declines in glucose-corrected sodium concentrations with those who had rising or stable concentrations. Children were randomly assigned to 1 of 4 intravenous fluid protocols that differed in infusion rate and sodium content. Data from the first 4, 8, and 12 hours of treatment were analyzed for 1251, 1086, and 877 episodes, respectively.

RESULTS

In multivariable analyses, declines in glucose-corrected sodium concentrations were associated with higher sodium and chloride concentrations at presentation and with previously diagnosed diabetes. Treatment with 0.45% (vs 0.9%) sodium chloride fluids was also associated with declines in sodium concentration; however, higher rates of fluid infusion were associated with declines in sodium concentration only at 12 hours. Frequencies of abnormal Glasgow Coma Scale scores and clinical diagnoses of cerebral injury were similar in patients with and without declines in glucose-corrected sodium concentrations.

CONCLUSIONS

Changes in glucose-corrected sodium concentrations during DKA treatment are influenced by the balance of free-water loss versus sodium loss at presentation and the sodium content of intravenous fluids. Declines in glucose-corrected sodium concentrations are not associated with mental status changes during treatment.

Address: Departments of Pediatrics [email protected].; Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and School of Medicine, The Ohio State University, Columbus, Ohio.; Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital and The Warren Alpert Medical School, Brown University, Providence, Rhode Island.; Division of Critical Care Medicine, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital and College of Physicians and Surgeons, Columbia University, New York City, New York.; Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.; Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado.; Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center and School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia.; Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois.; Division of Emergency Medicine, Department of Pediatrics, St Louis Children's Hospital and School of Medicine, Washington University in St Louis, St Louis, Missouri.; Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.; Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.; Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.; Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts.; Emergency Medicine, School of Medicine, University of California, Davis Health, University of California, Davis, Sacramento, California.; Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah.; Department of Psychology, University of California, Davis, Davis, California.

DOI: 10.1542/peds.2021-050243

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MeSH Terms: Child, Chlorides, Diabetic Ketoacidosis, Female, Fluid Therapy, Glasgow Coma Scale, Humans, Male, Prospective Studies, Sodium, Sodium Chloride