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Why do patients with diabetic ketoacidosis have cerebral swelling, and why does treatment sometimes make it worse?

WHEN I was a resident and young faculty member (distant past, to be sure), I took part in the care and monitoring of many patients with diabetic ketoacidosis (DKA), and, unless they were moribund on admission (which was rare), they always recovered fully. Some years later I became aware of patients who either died or suffered central nervous system (CNS) injury while receiving treatment for DKA. On analyzing the data of these patients, I noticed that the style of resuscitation for these patients had changed from that of the 1950s to include more free water administration; this style was supported by the pediatric textbooks. We had all ignored the fact that DKA almost always results in hyperosmolality, which calls for an adjustment in the style of management. Unfortunately, many tragic outcomes have occurred in the interim. A plethora of malpractice suits has followed, in which it would be hard to