What is the optimal IV fluid for significant dehydration with hyperketonemia, and are dextrose-containing fluids beneficial?

From the Guidelines

For significant dehydration with elevated ketones, normal saline (0.9% NaCl) is typically the best initial IV fluid choice, as it effectively corrects the volume deficit and begins addressing electrolyte imbalances 1. Begin with a bolus of 1-2 L in adults or 20 mL/kg in children, followed by maintenance fluids based on ongoing assessment. Dextrose-containing fluids are indeed helpful once initial volume resuscitation has been established, particularly in diabetic ketoacidosis (DKA), as they help prevent hypoglycemia while continuing insulin therapy 1. After the initial saline bolus, adding D5W or D5NS (5% dextrose in water or normal saline) is recommended when blood glucose falls below 250 mg/dL, as suggested by the protocol for the management of adult patients with DKA 1. This approach addresses both the dehydration and the metabolic derangement, with the rationale that saline first corrects the volume deficit and begins addressing electrolyte imbalances, while subsequent dextrose administration helps shut off ketogenesis by promoting insulin action and reducing counterregulatory hormone effects. Key considerations include:

• Potassium replacement, typically added after confirming adequate renal function and urine output
• Regular monitoring of electrolytes, glucose, and acid-base status to guide ongoing fluid and electrolyte management
• Adjusting the infusion rate and composition based on the patient's response, such as changing to 5% dextrose and 0.45–0.75% NaCl once serum glucose reaches 250 mg/dL, as recommended for pediatric patients [<20 years of age] 1. However, the most recent and highest quality study 1 recommends using water with dextrose or glucose for intravenous rehydration, but this is more relevant to congenital nephrogenic diabetes insipidus, and the context of significant dehydration with elevated ketones may require a different approach, prioritizing initial volume resuscitation with normal saline.

From the FDA Drug Label

INDICATIONS AND USAGE 50% Dextrose Injection is indicated in the treatment of insulin hypoglycemia (hyperinsulinemia or insulin shock) to restore blood glucose levels. The best IV fluid for significant dehydration with elevated ketones is not specified in the provided drug label.

• Dextrose containing fluids may be helpful in treating hypoglycemia, but their use in significant dehydration with elevated ketones is not directly addressed.
• The label does indicate that dextrose can be used as a source of carbohydrate calories in patients with restricted oral intake, but this does not necessarily apply to the treatment of dehydration with elevated ketones. 2

From the Research

IV Fluids for Significant Dehydration with Elevated Ketones

• The best IV fluid for significant dehydration with elevated ketones is a matter of debate, with different studies suggesting various options.
• A study published in the Journal of pharmacy practice 3 found that balanced fluids were associated with a shorter time to diabetic ketoacidosis (DKA) resolution compared to normal saline.
• Another study published in Pediatric endocrinology, diabetes, and metabolism 4 compared the effects of hypertonic saline solution and normal saline solution on children with DKA, and found that both were equally effective in terms of hemodynamic improvement, resolution of acidosis, and correction of hyperglycemia.

Use of Dextrose-Containing Fluids

• The addition of dextrose to IV crystalloid therapy may provide clinical benefit in acute dehydration, particularly in patients with ketosis who are not tolerating oral glucose 5.
• A systematic review and meta-analysis published in CJEM 5 found that the addition of dextrose to intravenous rehydration solutions did not result in decreased hospital admissions or other clinically important benefits among dehydrated children or adults.
• However, the study noted that the confidence intervals around the estimate of effect were wide and included the possibility of substantial benefit, suggesting that further research is needed to fully understand the role of dextrose-containing fluids in the treatment of dehydration.

Assessment of Dehydration

• Clinical assessment of dehydration can be poor, and may overestimate the severity of dehydration 6.
• A study published in the Journal of the American Medical Directors Association 7 emphasized the importance of a thorough appraisal of the patient, laboratory testing, and knowledge of the patient's history in diagnosing dehydration.
• The study also noted that dehydration is rarely due to neglect, but rather results from a combination of physiological and disease processes.