When to discontinue intravenous fluids in diabetic ketoacidosis (DKA)?

From the Guidelines

Intravenous fluids in diabetic ketoacidosis (DKA) should be discontinued when the patient is hemodynamically stable, able to tolerate oral intake, and shows resolution of metabolic acidosis, as indicated by a blood glucose <200-250 mg/dL, serum bicarbonate >15-18 mEq/L, and a venous pH of 7.3, according to the most recent guidelines 1. The decision to discontinue intravenous fluids in DKA is based on the patient's clinical status and laboratory parameters. Key factors to consider include:

• Hemodynamic stability, characterized by a normal blood pressure (typically systolic >90 mmHg without vasopressors) and heart rate <100 beats/minute
• Ability to tolerate oral intake
• Resolution of metabolic acidosis, as indicated by a serum bicarbonate >15-18 mEq/L, anion gap has normalized (<12 mEq/L), and a venous pH of 7.3
• Blood glucose <200-250 mg/dL When these criteria are met, the patient can be transitioned from IV insulin to subcutaneous insulin, typically giving the first subcutaneous dose 1-2 hours before stopping the insulin infusion to ensure continuous insulin coverage 1. The rationale for this approach is that continuing IV fluids beyond clinical resolution can lead to fluid overload, particularly in patients with cardiac or renal impairment, as noted in previous studies 1. Additionally, once ketoacidosis resolves and the patient can drink fluids, the physiological need for IV hydration diminishes, and careful monitoring during this transition period is essential to prevent recurrence of DKA or other complications. It is also important to note that the use of bicarbonate in people with DKA has been shown to make no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1.

From the Research

Discontinuation of Intravenous Fluids in Diabetic Ketoacidosis (DKA)

• The decision to discontinue intravenous fluids in DKA should be based on the patient's clinical status and laboratory results, including the resolution of metabolic acidosis and the achievement of adequate hydration 2.
• 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 IV fluid solutions, such as lactated Ringers, may be associated with faster DKA resolution and shorter hospital stays compared to isotonic normal saline 3, 4, 5.
• A systematic review and meta-analysis found that balanced electrolyte solutions resolve DKA faster than 0.9% saline, with a mean difference of -5.36 hours 5.
• A controlled trial found that using Hartmann's solution, a balanced salt solution, in DKA did not shorten the time to normalize acid-base status compared to 0.9% normal saline, but may benefit patients with severe DKA 6.
• The discontinuation of intravenous fluids should be considered when the patient's metabolic acidosis has resolved, and they are able to tolerate oral hydration and nutrition 2.
• It is essential to monitor the patient's electrolyte levels, particularly potassium, phosphate, and magnesium, and to replace them as needed to prevent complications 2.
• The use of sodium bicarbonate should be avoided, except in cases where the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema 2.