Diabetic ketoacidosis (DKA) is a life-threatening yet preventable complication of type 1 diabetes. Fluids are the crucial elements of DKA therapy that help restore intravascular, interstitial, and intracellular compartments. Hydration ameliorates hyperglycemia by decreasing counter-regulatory hormones, enhancing renal glucose clearance, and augmenting insulin sensitivity. 

However, the last several decades have witnessed intense debate about fluids in DKA owing to their possible role in cerebral edema (CE) causation. There have been modifications in Rehydration protocols to prevent major osmotic shifts, correct electrolyte imbalances, and avoid cerebral or pulmonary edema.

In DKA, the preferred conservative deficit speculation ranges from 6.5% to 8.5%. Normal saline (0.9%) remains the traditional fluid of choice for both volume resuscitation and deficit replacement in DKA. However, the risk of AKI with its liberal chloride content remains controversial. On the contrary, balanced crystalloids with restricted chloride content need more investigation in children with DKA, both concerning DKA resolution and AKI. Although fluids are integral to DKA management, a fine balance is needed to avoid under-hydration or over-hydration during DKA management. 

Jayashree M, Williams V, Iyer R. Fluid Therapy For Pediatric Patients With Diabetic Ketoacidosis: Current Perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2019;12:2355-2361. DOI: 10.2147/DMSO.S194944