From the Guidelines
For patients with diabetic ketoacidosis (DKA), I recommend using normal saline (NS) rather than lactated Ringer's (LR) for initial fluid resuscitation. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of individualized treatment and aggressive fluid management in DKA patients 1.
Key Considerations for Fluid Resuscitation
- The goal of fluid resuscitation is to restore circulatory volume and tissue perfusion, resolve ketoacidosis, and correct electrolyte imbalance and acidosis.
- NS is preferred over LR because it provides chloride ions that help restore the anion gap, correcting the metabolic acidosis present in DKA.
- LR contains lactate, which requires hepatic metabolism to bicarbonate, but patients with DKA often have impaired liver function, making this conversion less efficient.
- The potassium content in LR may also be problematic since DKA patients can have variable potassium levels.
Initial Fluid Resuscitation Protocol
- Start with NS at 15-20 mL/kg/hr (typically 1-1.5 L) in the first hour.
- Reduce to 250-500 mL/hr depending on hemodynamic status and hydration.
- Monitor patient's response to fluid resuscitation and adjust as needed.
Transition to Dextrose-Containing Fluids
- After the initial resuscitation phase and once the patient's serum glucose falls below 200-250 mg/dL, transition to dextrose-containing fluids (like D5NS or D5½NS) to prevent hypoglycemia.
- Continue insulin therapy to resolve the ketoacidosis, with the goal of transitioning from intravenous to subcutaneous insulin as soon as possible 1.
Additional Considerations
- Treat any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke.
- Provide adequate fluid replacement, frequent bedside testing, and appropriate treatment of any concurrent infections.
- Monitor patient's mental status and laboratory results closely to avoid recurrent DKA and other complications.
From the Research
Comparison of LR and NS in DKA Management
- The use of lactated Ringers (LR) versus normal saline (NS) in the management of diabetic ketoacidosis (DKA) has been studied in several research papers 2, 3, 4, 5.
- Studies have shown that LR is associated with faster time to DKA resolution compared to NS 3, 4, 5.
- The use of LR has also been linked to a shorter duration of insulin infusion compared to NS 4.
- Additionally, LR has been found to reduce the risk of complications related to hyperchloremia, such as non-anion gap metabolic acidosis 2.
- However, some studies have found no significant difference in hospital or intensive care unit length of stay between LR and NS groups 3, 5.
Key Findings
- A study published in Cureus found that large-volume resuscitation with NS was associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis 2.
- A study published in the Journal of pharmacy practice found that balanced fluids, such as LR, were associated with a shorter time to DKA resolution compared to NS 3.
- A study published in the Journal of diabetes science and technology found that protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip 4.
- A study published in Pharmacotherapy found that treatment with LR as the primary crystalloid for acute DKA management was associated with faster high anion gap metabolic acidosis resolution compared with NS 5.
Considerations for DKA Management
- The management of DKA requires careful consideration of fluid resuscitation, insulin therapy, and electrolyte replacement 6.
- Different society guidelines have inconsistencies in their recommendations, and some aspects of treatment are not precise enough or have not been thoroughly studied 6.
- Patient factors and comorbidities, such as pregnancy, renal disease, and congestive heart failure, should receive careful attention and consideration in DKA management 6.