From the Guidelines
In patients with diabetic ketoacidosis (DKA), intravenous (IV) fluids should be changed when glucose levels reach approximately 200-250 mg/dL, at which point 0.9% NaCl or other crystalloid can be switched to 5% dextrose with 0.45% sodium chloride at a clinically appropriate rate to prevent hypoglycemia while continuing insulin therapy. The management of IV fluids in DKA patients is crucial and should be based on the patient's hydration status, electrolyte levels, and response to initial therapy 1. Initially, 0.9% NaCl or other crystalloid should be administered at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8-12 hours 1. The goal is to keep glucose between 150 and 200 mg/dL until resolution, and target glucose to between 200 and 250 mg/dL until resolution for moderate or severe DKA 1. It is essential to monitor electrolytes, particularly potassium, every 2-4 hours, as insulin therapy drives potassium into cells and can cause hypokalemia 1. The fluid type and rate should be adjusted based on regular monitoring of electrolytes and hemodynamic status, and potassium should be given in each liter of IV fluid as needed to keep serum potassium between 4 and 5 mmol/L 1. Careful fluid management is critical to prevent complications such as cerebral edema and to ensure timely recovery from DKA. Key considerations in fluid management include:
- Regular monitoring of electrolytes, particularly potassium
- Adjustment of fluid type and rate based on hemodynamic status and electrolyte levels
- Prevention of hypoglycemia by changing to 5% dextrose with 0.45% sodium chloride when glucose levels reach approximately 200-250 mg/dL
- Maintenance of insulin therapy alongside fluid management to ensure timely recovery from DKA.
From the Research
Fluid Management in Diabetic Ketoacidosis (DKA)
- The selection of intravenous (IV) fluids is a key area in the treatment of DKA, with isotonic normal saline remaining the standard for initial fluid resuscitation 2.
- However, balanced solutions have been shown to have faster DKA resolution 2, 3, 4.
- Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 2.
- The use of balanced crystalloids, such as lactated Ringer's, may offer an advantage over normal saline for the treatment of patients with DKA, with faster time to high anion gap metabolic acidosis resolution and similar incidence of complications 3.
- A study comparing balanced fluids versus normal saline for initial fluid resuscitation in adults with DKA found that balanced fluids were associated with a shorter time to DKA resolution 4.
Timing of IV Fluid Change
- There is no specific recommendation on when to change IV fluids in a patient with DKA, but it is essential to monitor the patient's fluid status and adjust the IV fluids accordingly 2, 5.
- The goal of fluid therapy is to restore intravascular, interstitial, and intracellular compartments, and to avoid under-hydration or over-hydration 5.
- A conservative deficit assumption ranging from 6.5% to 8.5% is preferred, and normal saline has been the traditional fluid of choice for both volume resuscitation and deficit replacement in DKA 5.
- However, the risk of acute kidney injury with liberal chloride content remains a contentious issue, and balanced crystalloids with restricted chloride content may be a better option 5, 3, 4.
Monitoring and Adjustments
- Regular monitoring of electrolyte levels, including potassium, phosphate, and magnesium, is essential for DKA management 2.
- The use of IV sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema, but it may be considered in certain situations, such as serum pH below 6.9 or serum bicarbonate levels below 10 mEq/L 2.
- Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay 2.