From the Guidelines
The best fluid for treating diabetic ketoacidosis (DKA) is 0.9% NaCl or other crystalloid at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8–12 h. Initial fluid resuscitation should begin with rapid administration of fluids to restore intravascular volume, improve tissue perfusion, and enhance renal clearance of glucose and ketones. The choice of fluid should be based on the patient's hydration status, serum electrolyte levels, and urinary output. According to the most recent guidelines 1, 0.9% NaCl or other crystalloid is recommended as the initial fluid of choice.
- Key considerations in fluid management include:
- Replacing 50% of the estimated fluid deficit in the first 8-12 hours
- Administering fluids at a clinically appropriate rate
- Monitoring hemodynamic parameters and adjusting fluid rates accordingly
- Adding potassium to IV fluids as needed to maintain serum potassium levels between 4 and 5 mmol/L
- Insulin therapy should be administered alongside fluid therapy, typically an insulin infusion at 0.1 units/kg/hour, with regular monitoring of electrolytes, glucose, and acid-base status.
- The goal of fluid therapy is to restore intravascular volume, improve tissue perfusion, and enhance renal clearance of glucose and ketones, while minimizing the risk of complications such as cerebral edema.
- Regular monitoring of electrolytes, glucose, and acid-base status is crucial to guide fluid and insulin therapy, with adjustments made as needed to achieve optimal outcomes.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Fluid Management in Diabetic Ketoacidosis (DKA)
The choice of fluid for initial resuscitation in DKA patients is a crucial aspect of management. Several studies have compared the efficacy of different fluids, including normal saline and balanced solutions.
- Normal saline has been the traditional choice for fluid resuscitation in DKA patients 2, 3.
- However, recent studies suggest that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 4, 5.
- Balanced solutions, such as lactated Ringers, have been shown to be associated with faster correction of pH and earlier resolution of acidosis 2, 4.
- A systematic review of clinical trials found that balanced solutions were generally associated with faster correction of pH, although the time to reach overall DKA endpoints was comparable in both groups 2.
- A retrospective cohort study found that patients who received balanced fluids had a shorter time to DKA resolution compared to those who received normal saline 4.
- Another study found that large-volume resuscitation with isotonic normal saline was associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis 5.
Recommendations for Fluid Management
Based on the available evidence, the following recommendations can be made:
- Balanced crystalloids, such as lactated Ringers, may be a better choice for initial resuscitation in DKA patients due to their potential to reduce the risk of complications related to hyperchloremia and improve clinical outcomes 4, 5.
- Normal saline may still be used in certain situations, but its use should be carefully considered and monitored due to the potential risks associated with large volumes 2, 3.
- Further prospective studies are needed to confirm these findings and guide fluid management protocols in DKA 2, 5.
Key Findings
- Balanced solutions are associated with faster correction of pH and earlier resolution of acidosis 2, 4.
- Large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 4, 5.
- The choice of fluid for initial resuscitation in DKA patients should be carefully considered and monitored 2, 3, 4, 5.