Transitioning Fluid Management in Children With Diabetic Ketoacidosis

Monday, March 23, 2026

11:30 AM - 12:30 PM Central Time

Location: Connections Central - RST 10

Maya Gibson, MD (she/her/hers)

Children’s National Hospital, District of Columbia

Disclosure(s): No relevant financial relationship(s) to disclose.
JH

Josh Heffren, BCPPS, PharmD

Clinical Pharmacy Specialist
Children's National Hospital, District of Columbia

Disclosure information not submitted.
SM

Shideh Majidi, MD MSCS

Director of Diabetes Services
Children's National Hospital, District of Columbia

Disclosure information not submitted.
KB

Kathleen Brown, MD

Associate Chief for Quality and Safety, Division of Emergency Medicine
Children's National Hospital, District of Columbia

Disclosure information not submitted.
AS

Ashley Seidl, MS, RN, CPN

Professional Practice Specialist
Children's National Hospital, District of Columbia

Disclosure information not submitted.
MS

Matthew Sharron, MD

PICU Medical Unit Director
Children's National Hospital, District of Columbia

Disclosure information not submitted.
AK

Aadil Kakajiwala, MD

Director, Pediatric Acute Kidney Support Therapies
Children's National Hospital, District of Columbia

Disclosure information not submitted.
Boh L. Song, PharmD (she/her/hers)

Children's National Hospital, District of Columbia

Disclosure information not submitted.

Introduction: At our institution 0.9% sodium chloride (NaCl) is the standard fluid used during the initial resuscitation and repletion phase for patients presenting with diabetic ketoacidosis (DKA). This approach has been associated with a 48% incidence of hyperchloremia (serum chloride >110 mmol/L), which may worsen metabolic acidosis and lead to delayed DKA resolution (current mean time is 19.0 hours ± 14.3 hours). In contrast, balanced crystalloids are associated with lower risk of hyperchloremia.

Methods: For patients admitted with diabetic ketoacidosis (DKA), we aim to implement a quality improvement initiative transitioning fluid management from 0.9% NaCl to Plasma-Lyte®, with the goal of decreasing the incidence of hyperchloremia from 48% to 25% and reducing the time to DKA resolution between August 2025 and February 2026, while sustaining these improvements thereafter. A multidisciplinary team comprising of Endocrinology, Emergency Medicine, and Intensive Care collaborated to identify key drivers contributing to the high incidence of hyperchloremia in DKA management. Using the Plan-Do-Study-Act (PDSA) framework, the team implemented targeted interventions, including staff education, updates to the electronic medical record order sets, and redesign of clinical workflows. Data will be collected after the intervention to evaluate its effectiveness and impact on patient outcomes.

Results: Pre-intervention analysis reviewing the utilization of 0.9% NaCl suggested that hyperchloremia led to delayed DKA resolution. These findings support further investigation into the use of Plasma-Lyte ® as a potential strategy to improve DKA outcomes. The project is currently in progress. An education curriculum has been developed to reflect the changes in the transition of fluid management. Full data analysis will be conducted upon completion of PDSA cycles and follow-up measurement periods. The primary outcomes of interest are incidence of hyperchloremia and time to DKA resolution.

Conclusions: Although final outcomes are being evaluated, early implementation efforts have revealed important challenges, particularly in achieving stakeholder agreement. These insights underscore the importance of multidisciplinary collaboration and iterative feedback in driving and sustaining meaningful improvements in DKA management.