From the Guidelines
The maximum fluid rate in diabetic ketoacidosis (DKA) should not exceed 1.5 times the 24-hour maintenance requirements, approximately 4-14 mL/kg/hour, with careful monitoring of hemodynamic status and serum osmolality to avoid complications like cerebral edema, as recommended by the most recent guidelines 1.
Key Considerations
- Initial fluid resuscitation should use isotonic saline (0.9% NaCl) at a rate of 10-20 mL/kg/hour for the first hour, with a total fluid replacement goal of 50 mL/kg over the first 4-6 hours.
- Fluid choice should be guided by serum sodium levels, with 0.45% saline often used once serum sodium normalizes or increases.
- Particular caution is needed in patients with cardiac or renal compromise, and in children and elderly patients who are at higher risk for cerebral edema.
- Fluid administration should be adjusted based on hemodynamic status, with careful monitoring of vital signs, urine output, and mental status.
Monitoring and Adjustments
- Serum osmolality should be monitored closely to avoid excessive changes, with a goal of not exceeding 3 mOsm/kg/hour.
- Electrolyte replacement, particularly potassium, should be initiated once renal function is assured, with a goal of maintaining serum potassium levels between 4 and 5 mmol/L.
- Frequent monitoring of glucose, electrolytes, and acid-base status is crucial to guide adjustments in fluid and insulin therapy.
Insulin Administration
- Insulin administration should be initiated concurrently with fluid therapy, with a goal of maintaining blood glucose levels between 150 and 200 mg/dL.
- The choice of insulin regimen, including the use of intravenous or subcutaneous insulin, should be individualized based on patient factors and clinical response.
From the Research
Maximum Fluid Rate in DKA
- The maximum fluid rate in DKA is a topic of ongoing research and debate.
- A study from 1987 2 suggests that 2 to 3 liters of isotonic saline at 500 ml/hr can be used to replace extracellular fluids in patients with DKA.
- Another study from 1997 3 compared two therapeutic regimes with different repletion rates (1000 ml/h and 500 ml/h) and found that both groups had similar biochemical characteristics at admission and that there was no significant difference in any of the metabolic determinations among the different groups along the evolution.
- More recent studies have focused on the comparison between balanced crystalloids and saline for fluid resuscitation in DKA. A 2020 study 4 found that treatment with balanced crystalloids resulted in more rapid resolution of DKA compared to saline.
- A 2025 study 5 suggests that large-volume resuscitation with isotonic normal saline is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis, supporting the use of balanced crystalloids for initial resuscitation in DKA patients.
- Another 2025 study 6 found that balanced fluids were associated with a shorter time to DKA resolution compared to normal saline.
- The optimal maximum fluid rate for DKA treatment may depend on various factors, including the patient's individual needs and the specific fluid used for resuscitation, as evidenced by the varying results of studies 2, 3, 4, 5, 6.