From the Guidelines
The best IV fluid choice in starvation ketosis is dextrose-containing solutions, specifically D5W (5% dextrose in water) or D10W (10% dextrose in water), with the addition of appropriate electrolytes as needed. This approach is supported by the most recent and highest quality study, which recommends using water with dextrose or glucose for intravenous rehydration 1. The use of dextrose-containing solutions provides necessary carbohydrates to suppress ketone production while avoiding complications like refeeding syndrome.
Key Considerations
- Initial administration should be at a moderate rate of 100-125 mL/hour to avoid rapid shifts in glucose and insulin levels.
- Dextrose administration inhibits further ketogenesis by stimulating insulin release, which blocks fatty acid breakdown and subsequent ketone formation.
- For patients with prolonged starvation, thiamine (100 mg IV) should be administered before dextrose to prevent Wernicke's encephalopathy.
- Electrolyte abnormalities, particularly hypokalemia, hypophosphatemia, and hypomagnesemia, should be monitored and corrected as they commonly occur when reintroducing carbohydrates.
- In cases of severe acidosis, balanced crystalloids like lactated Ringer's may be added to help correct acidemia while providing volume resuscitation if needed.
Rationale
The recommendation for dextrose-containing solutions is based on the principle of providing necessary carbohydrates to suppress ketone production while avoiding complications like refeeding syndrome. This approach is supported by recent studies, including the 2025 international expert consensus statement on the diagnosis and management of congenital nephrogenic diabetes insipidus, which recommends using water with dextrose or glucose for intravenous rehydration 1. Additionally, the 2025 standards of care in diabetes emphasize the importance of individualized treatment and careful clinical and laboratory assessment in managing hyperglycemic states, including starvation ketosis 1.
Clinical Implications
The use of dextrose-containing solutions in starvation ketosis has significant clinical implications, including the potential to reduce morbidity and mortality by suppressing ketone production and avoiding complications like refeeding syndrome. By providing necessary carbohydrates and electrolytes, dextrose-containing solutions can help restore circulatory volume and tissue perfusion, resolve hyperglycemia, and correct electrolyte imbalance and ketosis. Overall, the use of dextrose-containing solutions in starvation ketosis is a critical component of evidence-based practice, and healthcare providers should prioritize this approach to optimize patient outcomes.
From the Research
IV Fluid Choice in Starvation Ketosis
- The best IV fluid choice in starvation ketosis is not directly addressed in the provided studies, but we can look at similar conditions such as diabetic ketoacidosis for guidance.
- Studies on diabetic ketoacidosis suggest that balanced electrolyte solutions (BES) may be a better choice than 0.9% saline for fluid resuscitation 2, 3.
- A systematic review and meta-analysis found that BES resolves diabetic ketoacidosis faster than 0.9% saline, with a mean difference of -5.36 hours 3.
- Another study found that Hartmann's solution, a type of BES, is an acceptable alternative to 0.9% saline in diabetic ketoacidosis, and may benefit those with severe DKA 2.
- In the context of starvation ketosis, it is likely that a balanced electrolyte solution would be a better choice than 0.9% saline, but more research is needed to confirm this.
- Management of starvation ketoacidosis is often empirical, involving close monitoring of fluid status and electrolytes, and clinicians should discuss the risk of ketoacidosis associated with the ketogenic diet in women who plan to breast-feed and lose weight following pregnancy 4.
Key Considerations
- Balanced electrolyte solutions may be a better choice than 0.9% saline for fluid resuscitation in starvation ketosis, based on evidence from similar conditions such as diabetic ketoacidosis.
- Close monitoring of fluid status and electrolytes is crucial in the management of starvation ketoacidosis.
- Clinicians should be aware of the potential risks associated with a strict ketogenic diet, especially in breast-feeding mothers, and discuss these risks with patients 5, 4.