From the Guidelines
Lactated Ringer’s or normal saline solution should be administered as the best IV fluid for significant dehydration with elevated ketones. According to the 2017 Infectious Diseases Society of America clinical practice guidelines 1, isotonic intravenous fluids such as these are recommended for severe dehydration, shock, or altered mental status, and can also be beneficial in people with ketonemia to enable tolerance of oral rehydration.
Key Considerations
- For significant dehydration, especially with elevated ketones, the primary goal is to restore fluid volume and improve renal perfusion to enhance ketone clearance.
- Lactated Ringer’s and normal saline solution are both effective for this purpose, with the choice between them depending on the patient's specific electrolyte needs and clinical context.
- Administration should be tailored to the individual's response, with initial boluses followed by maintenance fluids as needed.
- Monitoring of electrolytes, particularly potassium, and blood glucose levels is crucial during rehydration therapy.
- The addition of dextrose to IV fluids may be considered once the initial volume deficit is corrected, especially if insulin is being administered, to prevent hypoglycemia.
Clinical Application
- In adults, an initial bolus of 1-2 liters of lactated Ringer’s or normal saline over 1-2 hours can be followed by maintenance fluids at 150-250 mL/hour, adjusting based on clinical response.
- For children, a bolus of 10-20 mL/kg over 1-2 hours, followed by maintenance fluids based on weight, can be an appropriate approach.
- Regular assessment of the patient's hydration status, electrolyte balance, and ketone levels will guide the adjustment of IV fluid therapy.
From the Research
Dehydration with Elevated Ketones
- Significant dehydration with elevated ketones is a condition that requires prompt medical attention, often seen in diabetic ketoacidosis (DKA) 2, 3, 4, 5.
- The mainstays of treatment for DKA include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 2.
IV Fluid Choice
- The choice of IV fluid for significant dehydration with elevated ketones is crucial, with options including normal saline (NS) and lactated Ringer's (LR) 4.
- A study comparing LR to NS in the management of acute DKA found that LR was associated with faster time to high anion gap metabolic acidosis resolution compared to NS 4.
- However, no difference was found in complications such as incidence of nongap metabolic acidosis, hyperchloremia, acute kidney injury, and new renal replacement therapy between the LR and NS groups 4.
Dehydration Assessment
- Clinical assessment of dehydration in DKA patients is often poor and may overestimate the percent dehydration 3.
- A study found that patients with DKA had moderate (4% to 8%) dehydration, and initial fluid therapy should assume moderate dehydration with adjustments made according to clinical response 3.