From the Guidelines
Fluid resuscitation in patients with diabetic ketoacidosis (DKA) and heart failure should be managed with a conservative approach, using isotonic saline (0.9% NaCl) at a reduced rate, aiming to replace 50% of the estimated fluid deficit in the first 8-12 hours, as recommended by the 2025 standards of care in diabetes 1. The initial fluid management should prioritize correcting dehydration while avoiding fluid overload, which is crucial in patients with heart failure.
- Key considerations include:
- Determining hydration status and cardiac compromise
- Using 0.9% NaCl or other crystalloid at a clinically appropriate rate
- Hemodynamic monitoring and pressors as needed
- Adjusting insulin and potassium administration according to glucose and electrolyte levels
- Monitoring urine output, cardiac status, and serum electrolytes every 2-4 hours until stable. This approach is supported by the latest guidelines, which emphasize the importance of individualized care and careful monitoring in patients with DKA and heart failure 1.
- Additional measures may include:
- Using diuretics if signs of fluid overload develop
- Implementing central venous pressure monitoring or bedside echocardiography in severe cases
- Adjusting the fluid replacement rate based on the patient's response and cardiac status. By following this cautious approach, clinicians can effectively manage fluid resuscitation in patients with DKA and heart failure, minimizing the risk of complications and improving outcomes 1.
From the Research
Fluid Resuscitation in DKA with Heart Failure
- The management of fluid resuscitation in patients with diabetic ketoacidosis (DKA) and heart failure requires careful consideration of the type and amount of fluid to be administered.
- A study published in 2024 found that fluid resuscitation with balanced electrolyte solutions results in faster resolution of DKA than with 0.9% saline in adults 2.
- The use of balanced crystalloids with restricted chloride content may be beneficial in patients with DKA and heart failure, as they can help to reduce the risk of hyperchloremia and acidosis 3, 4.
- However, the optimal fluid resuscitation strategy for patients with DKA and heart failure is not well established, and further research is needed to determine the best approach 5, 6.
Key Considerations
- The type and amount of fluid to be administered should be individualized based on the patient's clinical status and laboratory values.
- The use of normal saline (0.9%) may be associated with a higher risk of hyperchloremia and acidosis, particularly in patients with heart failure 2, 3.
- Balanced electrolyte solutions, such as Plasma-Lyte A, may be a more physiological alternative to normal saline and can help to reduce the risk of hyperchloremia and acidosis 3, 4.
- The rate and amount of fluid administration should be carefully monitored to avoid over-hydration or under-hydration, particularly in patients with heart failure 5, 6.
Laboratory Values and Outcomes
- The use of balanced electrolyte solutions has been shown to result in faster correction of metabolic acidosis and lower chloride levels compared to normal saline 2, 3, 4.
- The duration of insulin infusion and mortality rates were not significantly different between patients receiving balanced electrolyte solutions and those receiving normal saline 2, 3.
- Further research is needed to determine the optimal fluid resuscitation strategy for patients with DKA and heart failure and to evaluate the effects on clinical outcomes 5, 6.