A 7-year-old child with newly diagnosed type 1 diabetes presents with diabetic ketoacidosis: pH 7.10, blood glucose 480 mg/dL, K+ 5.2 mEq/L. Which fluid management strategy during the first 4 hours carries the HIGHEST risk of cerebral edema?

• A Rapid bolus of 20 mL/kg 0.9% saline in the first hour
• B Slow correction of fluid deficit over 48 hours
• C Bicarbonate administration for pH <7.1
• D Use of hypotonic fluid (0.45% saline) as initial rehydration ✓

Explanation

Rapid osmotic shifts from early hypotonic fluid use and rapid free water correction are strongly linked to cerebral edema in pediatric DKA. Standard protocol uses isotonic saline for initial resuscitation and slow deficit correction over 48-72 hours. Bicarbonate is not recommended routinely, and a single 20 mL/kg bolus of isotonic fluid is safe when indicated for hemodynamic instability.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.