What are the IV fluids of choice for a patient with Diabetic Ketoacidosis (DKA) and hypotension?

IV Fluid Management for DKA with Hypotension

For patients with diabetic ketoacidosis (DKA) and hypotension, initial fluid resuscitation should be with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour, followed by transition to balanced crystalloid solutions for maintenance fluid therapy. 1

Initial Resuscitation Phase

• First hour: Isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour to rapidly restore intravascular volume and address hypotension 1
• Fluid choice is guided by the need to quickly restore circulatory volume in hypotensive patients
• Aggressive initial fluid resuscitation is critical for reducing mortality and morbidity in DKA patients with hypotension

Maintenance Phase (After Initial Resuscitation)

After the initial resuscitation phase and once hemodynamic stability is achieved:

1. Transition to balanced crystalloid solutions (such as Lactated Ringer's or Plasma-Lyte) 1, 2, 3

   • Recent evidence shows balanced fluids result in faster DKA resolution compared to continued normal saline (13 hours vs 17 hours) 2
   • Balanced fluids are associated with less hyperchloremic metabolic acidosis 3

2. Fluid rate adjustment:

   • Adjust to 4-14 mL/kg/hour based on corrected sodium levels 1
   • Calculate corrected sodium using: Measured sodium + 1.6 × [(glucose mg/dL - 100)/100] 1

Monitoring and Adjustments

• Hourly monitoring of vital signs, neurological status, blood glucose, and fluid input/output 1
• Every 2-4 hours: Monitor electrolytes, BUN, creatinine, and venous pH 1
• Potassium management: Begin replacement when serum K+ <5.5 mEq/L by adding 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1
• Phosphate replacement: Include as KPO₄, especially with severe hypophosphatemia 1

Important Considerations and Pitfalls

• Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h) to prevent cerebral edema 1
• Adult vs. pediatric considerations: Adults with DKA may tolerate more aggressive fluid resuscitation than children, who are at higher risk for cerebral edema 4
• Monitor for complications: Watch for cerebral edema, hypoglycemia, hypokalemia, and fluid overload 1
• ICU admission criteria: Consider for cardiovascular instability, airway protection concerns, obtundation, or acute abdominal signs 4

Resolution Criteria

DKA is considered resolved when:

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3 1

The 2025 meta-analysis demonstrates that balanced crystalloid solutions resolve DKA faster than continued normal saline therapy (mean difference of -5.36 hours) with improved bicarbonate recovery and less hyperchloremia 3. However, initial resuscitation with isotonic saline remains important for rapid volume restoration in hypotensive patients.