From the Guidelines
In Diabetic Ketoacidosis (DKA), fluid replacement should be initiated prior to insulin administration. This approach is crucial because dehydration is a critical component of DKA, and administering fluids helps to restore circulating volume, reduce glucose levels, and improve renal function.
- The initial fluid of choice is isotonic saline (0.9% NaCl), which should be administered at a rate of 10-20 ml/kg/h in the first hour, with the goal of correcting estimated deficits within the first 24 hours 1.
- The induced change in serum osmolality should not exceed 3 mOsm/kg/h to avoid iatrogenic fluid overload.
- Potassium replacement is also essential, with a recommended dose of 20-40 mEq/l (2/3 KCl or potassium-acetate and 1/3 KPO4) once renal function is assured and serum potassium is known 1.
- Insulin therapy can be initiated once the patient is hemodynamically stable, with a recommended dose of 0.1 U/kg/h (5-7 U/h in adults) of regular insulin by continuous intravenous infusion 1.
- Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.
From the Research
Fluid Replacement in Diabetic Ketoacidosis (DKA)
- Fluid replacement is a crucial step in the treatment of DKA, as it helps to correct dehydration, acidosis, and electrolyte abnormalities 2, 3.
- The American Diabetes Association recommends that fluid replacement be initiated promptly in patients with DKA, with the goal of replacing the estimated fluid deficit over the first 24 hours 3.
- Insulin administration should be started after fluid replacement has been initiated, as insulin can worsen dehydration and electrolyte imbalances if given too early 3.
- The optimal fluid infusion rate and electrolyte content are still a topic of debate, but faster fluid administration rates have been shown to lead to a more rapid normalization of anion gap and Pco2 2.
- However, faster fluid administration rates have also been associated with an increased frequency of hyperchloremic acidosis, highlighting the need for careful monitoring and adjustment of fluid and electrolyte therapy 2.
Timing of Insulin Administration
- Insulin administration should be started after fluid replacement has been initiated, with the goal of reducing glucose levels and suppressing ketone production 3, 4.
- The use of a two-bag method, which allows for titration of dextrose delivery while keeping fluid, electrolyte, and insulin infusion rates constant, has been shown to be feasible and potentially beneficial in adult ED patients with DKA 4.
- This approach can help to reduce the risk of hypoglycemia and hypokalemia, and may lead to earlier correction of acidosis and discontinuation of insulin infusion 4.