At what rate should IV (intravenous) fluids be administered in diabetic ketoacidosis (DKA)?

IV Fluid Administration Rate in Diabetic Ketoacidosis (DKA)

For adult patients with DKA, initial fluid therapy should be isotonic saline (0.9% NaCl) at a rate of 15-20 mL/kg/hour during the first hour (approximately 1-1.5 liters in the average adult), followed by 4-14 mL/kg/hour of either 0.45% or 0.9% NaCl depending on corrected serum sodium levels. 1

Initial Fluid Resuscitation

Adults

1. First hour:

   • Isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour
   • Purpose: Expansion of intravascular and extravascular volume and restoration of renal perfusion
   • Average adult typically receives 1-1.5 liters during this period 1

2. Subsequent hours:

   • If corrected serum sodium is normal or elevated: 0.45% NaCl at 4-14 mL/kg/hour
   • If corrected serum sodium is low: 0.9% NaCl at 4-14 mL/kg/hour
   • Add potassium (20-30 mEq/L) once renal function is assured 1

Pediatric Patients (<20 years)

1. First hour:

   • Isotonic saline (0.9% NaCl) at 10-20 mL/kg/hour
   • Caution: Initial reexpansion should not exceed 50 mL/kg over first 4 hours due to risk of cerebral edema 1

2. Subsequent fluid therapy:

   • Calculate to replace deficit evenly over 48 hours
   • 0.45-0.9% NaCl (depending on serum sodium) at 1.5 times maintenance requirements (approximately 5 mL/kg/hour) 1
   • Add potassium (20-40 mEq/L) once renal function is assured and serum potassium is known 1

Monitoring and Adjustments

• Assess fluid replacement progress through:

  • Hemodynamic monitoring (improvement in blood pressure)
  • Fluid input/output measurement
  • Clinical examination 1

• Fluid replacement should correct estimated deficits within 24 hours for adults 1

• Rate of change in serum osmolality should not exceed 3 mOsm/kg/hour to avoid complications 1

• For patients with renal or cardiac compromise: Frequent assessment of cardiac, renal, and mental status is essential during fluid resuscitation 1

Special Considerations

• When serum glucose reaches 250 mg/dL in pediatric patients, change fluid to 5% dextrose with 0.45-0.75% NaCl 1

• Cerebral edema risk is higher in pediatric patients, particularly with rapid fluid administration 2

• In adults without severe volume depletion, some research suggests that a more modest infusion rate of 500 mL/hour may be as effective as 1000 mL/hour 3

Common Pitfalls to Avoid

1. Overly rapid fluid administration in pediatric patients can increase risk of cerebral edema

2. Inadequate potassium replacement can lead to dangerous hypokalemia as insulin therapy drives potassium into cells

3. Failure to adjust fluid type based on corrected serum sodium levels

4. Neglecting to monitor for fluid overload in patients with renal or cardiac compromise

5. Not transitioning to dextrose-containing fluids when glucose levels approach 250 mg/dL, which can lead to hypoglycemia

The fluid management approach must be accompanied by appropriate insulin therapy and electrolyte replacement to effectively treat DKA while minimizing complications that affect morbidity and mortality.