From the Guidelines
The initial IV fluid for treating diabetic ketoacidosis (DKA) is 0.9% NaCl or other crystalloid at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8–12 h. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of aggressive fluid resuscitation in DKA patients to restore intravascular volume, improve tissue perfusion, and enhance renal function 1.
Key Considerations
- The choice of initial IV fluid is crucial in the management of DKA, and 0.9% NaCl or other crystalloid is preferred due to its ability to rapidly expand intravascular volume and restore renal perfusion.
- The rate of fluid administration should be clinically appropriate, aiming to replace 50% of the estimated fluid deficit in the first 8–12 hours, with subsequent rates adjusted based on hemodynamic status and electrolyte levels.
- It is essential to monitor patients closely and adjust the fluid regimen as needed to avoid complications such as hypokalemia, which can be precipitated by insulin therapy 1.
Additional Recommendations
- Potassium replacement should be initiated once renal function is confirmed and serum potassium is below 5.0-5.2 mEq/L, as insulin therapy will drive potassium into cells and may precipitate hypokalemia.
- After the initial resuscitation phase, once the patient is hemodynamically stable and serum sodium levels are normal or elevated, the fluid may be changed to 0.45% sodium chloride (half-normal saline), especially if the corrected sodium is high.
- It is crucial to check electrolytes, renal function, venous pH, osmolality, and glucose every 2–4 hours until stable, and to adjust the treatment plan accordingly 1.
From the Research
Initial Intravenous (IV) Fluid for Diabetic Ketoacidosis (DKA)
- The initial intravenous (IV) fluid for Diabetic Ketoacidosis (DKA) is isotonic normal saline, as stated in the study 2.
- However, recent studies suggest that balanced solutions, such as lactated Ringers, may have faster DKA resolution and better clinical outcomes compared to normal saline 3.
- Isotonic saline is used for initial fluid resuscitation to restore volume status, followed by continuous IV insulin and electrolyte replacement 2.
- The degree of dehydration in DKA patients is typically moderate (4% to 8%), and initial fluid therapy should assume moderate dehydration with adjustments made according to clinical response 4.
- Other studies also support the use of isotonic saline as the initial replacement fluid, with potassium administered as required 5, 6.