Исследование показало, что большие объемы инфузий и 0,9% раствор хлорида натрия повышают риски у детей с диабетом

Larger bolus volumes may be less safe than smaller ones, and prolonged use of 0.9% saline may increase the risk of adverse events (AEs) in young patients with type 1 diabetes (T1D), according to findings from a systematic review and meta-analysis published in the Journal of the Endocrine Society. The primary management strategy for pediatric T1D with DKA is administration of fluid resuscitation followed by insulin. However, improper fluid management can result in cerebral injury. There is a lack of optimal rehydration consensus in pediatric DKA. Researchers conducted a systematic review and meta-analysis to evaluate the safety and efficacy of various pediatric fluid regimens. Publication databases were searched through June 2024 for relevant studies. A total of 10 randomized controlled trials (RCTs) were included in this analysis, including 5 from India, 4 from the United States, and 1 study from Australia. The studies examined various definitions for DKA and different fluid resuscitation regimens. Our findings support this conservative approach: smaller boluses suffice to improve perfusion without risking overload that might precipitate electrolyte shifts and hypoglycemia. Of the studies, 6 used 0.9% saline rehydration compared with balanced crystalloid solutions, or 0.45% saline, over a period of 48 hours as the intervention to treat DKA in pediatric patients. Conversely, insulin, glucose, and electrolyte administration protocols were similar in most studies, in which 0.1 U/kg/h insulin was administered intravenously with 40 mEq/L potassium, and 5% to 12.5% dextrose supplementation when blood glucose dropped below 200 to 300 mg/dL. Across the pooled study population of 2291 children and adolescents, those who received the 0.9% saline rehydration intervention vs other fluids had increased risk for hypoglycemia (risk ratio [RR], 1.35; 95% CI, 1.06-1.72; I2=0%; P =.01). However, no differential risk for cerebral injury (RR, 1.00; 95% CI, 0.61-1.63; I2=0%; P =1.00), hypokalemia (RR, 1.36; 95% CI, 0.85-2.18; I2=38%; P =.20), and overall morbidity (RR, 1.35; 95% CI, 0.96-1.91; I2= 19%; P =.09) was observed. In the 3 studies evaluating mortality, 1 study reported 0 deaths across both groups, while the remaining 2 studies reported deaths only in the comparator (other fluids) group (RR, 0.26; 95% CI, 0.03-2.31; I2=0%; P =.23). The rehydration strategies had similar hospital (mean difference [MD], -0.37; 95% CI, -4.83 to 4.08; I2=0%; P =.87) and intensive care unit (ICU; MD, 0.54; 95% CI, -11.59 to 12.66; I2=80%; P =.93) lengths of stay. In the safety analysis, patients who received 0.9% saline had a higher risk for adverse events (RR, 1.19; 95% CI, 1.07-1.33; I2=0%; P =.001), in which this trend was driven by the comparison with 0.45% saline (RR, 1.18; 95% CI, 1.05-1.31; I2=0%; P =.004). In the 0.9% saline intervention, an initial 20 mL/kg bolus increased risk for adverse events compared with an initial 10 mL/kg bolus (RR, 1.11; 95% CI, 1.01-1.23; I2=0%; P =.04). This analysis is limited by the inconsistent outcome measurement across RCTs; limited geographic diversity; and lack of data for a subgroup of pediatric patients who had presented with shock. The study authors concluded, “Our findings support this conservative approach: smaller boluses suffice to improve perfusion without risking overload that might precipitate electrolyte shifts and hypoglycemia.” References: Alam R, Memon F, Haryani A, et al. Fluid regimens for diabetic ketoacidosis in children and adolescents: systematic review and meta-analysis. J Endocr Soc. 2026;10(8):bvag148. doi:10.1210/jendso/bvag148/8733168