Fluids in the Treatment of Diabetic Ketoacidosis in Children: A Systematic Review.

AimTo determine the comparative effectiveness of fluid schemes for children with diabetic ketoacidosis (DKA).MethodsWe conducted a systematic review with an attempt to conduct network meta-analysis (NMA). We searched MEDLINE, EMBASE, CENTRAL, Epistemonikos, Virtual Health Library, and gray literature from inception to July 31, 2022. We included randomized controlled trials (RCTs) in children with DKA evaluating any intravenous fluid schemes. We planned to conduct NMA to compare all fluid schemes if heterogeneity was deemed acceptable.ResultsTwelve RCTs were included. Studies were heterogeneous in the population (patients and DKA episodes), interventions with different fluids (saline, Ringer's lactate (RL), and polyelectrolyte solution-PlasmaLyte (R)), tonicity, volume, and administration systems. We identified 47 outcomes that measured clinical manifestations and metabolic control, including single and composite outcomes and substantial heterogeneity preventing statistical combination. No evidence was found of differences in neurological deterioration (main outcome), but differences were found among interventions in some comparisons to normalize acid-base status (similar to 2 h less with low vs. high volume); time to receive subcutaneous insulin (similar to 1 h less with low vs. high fluid rate); length of stay (similar to 6 h less with RL vs. saline); and resolution of the DKA (similar to 3 h less with two-bag vs. one-bag scheme). However, available evidence is scarce and poor.ConclusionsThere is not enough evidence to determine the best fluid therapy in terms of fluid type, tonicity, volume, or administration time for DKA treatment. There is an urgent need for more RCTs, and the development of a core outcome set on DKA in children.