When to discontinue intravenous (IV) fluids in a patient with diabetic ketoacidosis (DKA)?

When to Discontinue IV Fluids in DKA Patients

IV fluids in diabetic ketoacidosis (DKA) should be discontinued when the patient has achieved resolution of DKA (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3) and is able to tolerate oral fluids. 1

Criteria for Discontinuing IV Fluids

The decision to discontinue IV fluids should be based on the following parameters:

Resolution of DKA

• Blood glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Resolution of ketonemia/ketonuria
• Improved mental status

Clinical Stability

• Hemodynamic stability (normal vital signs)
• Ability to tolerate oral intake
• No signs of volume depletion

Transitioning from IV to Subcutaneous Insulin

When discontinuing IV fluids, it's crucial to properly transition insulin therapy:

1. Start subcutaneous insulin before stopping IV insulin:

   • Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 1
   • Calculate total daily insulin requirement based on the average IV insulin infusion rate over previous 12-24 hours

2. Maintain target glucose levels:

   • For DKA: Keep glucose between 150-200 mg/dL until resolution 2
   • For HHS: Target glucose between 200-250 mg/dL until resolution 2

3. Continue monitoring:

   • Check blood glucose 2 hours after IV insulin discontinuation
   • Monitor every 3-4 hours for the first 24 hours after transition 1

Fluid Management Considerations

• Replace 50% of estimated fluid deficit in first 8-12 hours 2
• When transitioning to oral intake, ensure adequate hydration is maintained
• In patients with cardiac compromise, more cautious fluid administration is required 2

Potential Complications to Monitor

Discontinuing IV fluids too early may lead to:

• Rebound hyperglycemia
• Recurrence of ketosis
• Volume depletion
• Electrolyte abnormalities, particularly hypokalemia

Common complications during DKA treatment include:

• Hypoglycemia due to overzealous insulin treatment
• Hypokalemia from insulin administration and treatment of acidosis
• Hyperchloremic metabolic acidosis from excessive saline administration 2

Special Considerations

• Cerebral edema prevention: Gradual replacement of sodium and water deficits in hyperosmolar patients (maximal reduction in osmolality 3 mOsm/kg/h) 2
• Electrolyte management: Continue to monitor potassium levels as hypokalemia may occur during treatment 2
• Transition planning: Ensure proper discharge planning with education on DKA prevention and management 2

Follow-up Care

• Schedule outpatient follow-up within 1 month of discharge (or within 1-2 weeks if glycemic management medications were changed) 2
• Provide education on sick-day management, insulin administration, and when to seek medical attention 1
• Address any precipitating factors for DKA to prevent recurrence

By following these guidelines for discontinuing IV fluids in DKA patients, clinicians can ensure safe transitions from IV to oral hydration while maintaining metabolic stability and preventing complications.