What is the recommended fluid resuscitation strategy for Diabetic Ketoacidosis (DKA)?

Fluid Resuscitation in DKA

Initial Fluid Therapy

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour (approximately 1-1.5 liters in average adults) in the absence of cardiac compromise. 1

First Hour Resuscitation

• Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg body weight per hour for initial volume expansion and restoration of renal perfusion 1
• This translates to approximately 1-1.5 liters in the first hour for average-sized adults 1
• However, emerging evidence suggests balanced electrolyte solutions (BES) may be superior to normal saline, resolving DKA approximately 5.4 hours faster 2

Subsequent Fluid Management (After First Hour)

Fluid Selection Based on Corrected Sodium

• If corrected serum sodium is normal or elevated: Use 0.45% NaCl (half-normal saline) at 4-14 mL/kg/hour 1
• If corrected serum sodium is low: Continue 0.9% NaCl at 4-14 mL/kg/hour 1
• Correct serum sodium for hyperglycemia by adding 1.6 mEq to the measured sodium value for each 100 mg/dL glucose above 100 mg/dL 1

Potassium Replacement

• Once renal function is assured (adequate urine output), add 20-30 mEq/L potassium to IV fluids 1
• Use a mixture of 2/3 KCl and 1/3 KPO4 1
• Do not add potassium if serum K+ is <3.3 mEq/L until it is corrected, as insulin therapy will further lower potassium 1

Monitoring Parameters

Osmolality Control

• The induced change in serum osmolality must not exceed 3 mOsm/kg/hour to prevent cerebral edema 1
• This is particularly critical in pediatric patients where rapid osmolality shifts increase cerebral edema risk 1

Hemodynamic Assessment

• Monitor blood pressure improvement, fluid input/output, and clinical examination findings 1
• Correct estimated fluid deficits within 24 hours 1
• In patients with renal or cardiac compromise, perform frequent assessment of cardiac, renal, and mental status to avoid iatrogenic fluid overload 1

Special Considerations for Renal Compromise

In patients with chronic kidney disease, reduce standard fluid administration rates by approximately 50% to prevent volume overload. 3

• Initial rate should be 10-15 mL/kg/hour for the first hour, followed by 2-4 mL/kg/hour 3
• Monitor serum electrolytes, BUN, and creatinine every 2-4 hours 3
• Initiate potassium replacement only when serum potassium falls below 5.0 mEq/L and adequate urine output is confirmed 3

Pediatric Modifications

For patients under 20 years of age, use more conservative fluid resuscitation to minimize cerebral edema risk. 1

• Initial fluid: 0.9% NaCl at 10-20 mL/kg/hour for the first hour 1
• Do not exceed 50 mL/kg over the first 4 hours 1
• Continue with 0.45-0.9% NaCl (depending on sodium levels) at 1.5 times maintenance requirements (approximately 5 mL/kg/hour) 1
• Replace fluid deficit evenly over 48 hours rather than 24 hours as in adults 1

Emerging Evidence: Balanced Electrolyte Solutions

Recent high-quality evidence suggests balanced electrolyte solutions may be preferable to normal saline for DKA resuscitation. 4, 2

• A 2024 meta-analysis found BES resolves DKA 5.36 hours faster than normal saline (mean difference -5.36 hours, 95% CI: -10.46 to -0.26) 2
• BES results in lower post-resuscitation chloride (4.26 mmol/L lower) and higher bicarbonate levels (1.82 mmol/L higher) 2
• A 2025 retrospective study confirmed faster DKA resolution with BES (13 hours vs 17 hours, P=0.02) 4
• BES prevents hyperchloremic metabolic acidosis associated with large-volume normal saline resuscitation 5

Practical Application

While traditional guidelines recommend normal saline 1, consider using balanced electrolyte solutions (such as Plasma-Lyte A or Lactated Ringer's) as the primary resuscitation fluid based on recent evidence showing faster DKA resolution and prevention of hyperchloremic acidosis 4, 2, 5

Critical Pitfalls to Avoid

• Never administer excessive fluid in patients with renal or cardiac compromise—this precipitates pulmonary edema 1, 3
• Never add potassium to IV fluids before confirming adequate renal function and urine output 1
• Never allow osmolality to decrease faster than 3 mOsm/kg/hour—this causes cerebral edema, especially in children 1
• Never use standard adult DKA fluid protocols in pediatric patients without modification 1
• Never exceed 50 mL/kg in the first 4 hours in pediatric patients 1