Question normal

First of huge congratulations on an amazing study, well done to you both.

I'm interested in how you see the future of DKA initial fluid management evolving? I have attached a picture of initial fluid bolus phase of our DKA guidance below. It's pretty conservative guidance but based on UK national guidance (bsped.org.uk/media/1381/dkagui...)

As you are probably aware your study turns this on its head!

Even with changes to this if we take a 35Kg child in DKA (pH 7.18) you'd calculate a need for 4340mls needed in the first 24 hours (if 10% dry and 1mls/kg/hr). A fluid bolus (20mls/kg) would be 16% of total volume or just under 4 hours of the maintenance amount. As a proportion of total fluids it's not that much. Should we be considering then (if really wanting to replace fluid deficit rapidly) larger fluid boluses up to 40-60mls/kg

If not, why not? - where does safe resuscitation end (you've shown 20mls/kg is fine) and unsafe begin?

I appreciate this is a little provocative but I share this in the hope others have thought it and to stimulate debate!

Once again - well done on delivering what will probably be one of the landmark RCTs in Paediatric care of the decade.