Preferred Dextrose-Containing Fluid in DKA
When serum glucose reaches 250 mg/dL during DKA treatment, switch to 5% dextrose in 0.45% saline (D5W with half-normal saline) with appropriate potassium supplementation. 1, 2
Timing of Dextrose Introduction
- Do not add dextrose to IV fluids until plasma glucose falls to 250 mg/dL 1, 3
- Continue insulin infusion at 0.1 unit/kg/hour even after adding dextrose, as insulin is needed to clear ketoacidosis, not just lower glucose 3
- The goal is to maintain glucose between 150-200 mg/dL while continuing insulin therapy until ketoacidosis resolves (pH >7.3, bicarbonate ≥18 mEq/L) 1
Specific Fluid Composition
For adults: Use D5W with 0.45% NaCl (5% dextrose in half-normal saline) once glucose reaches 250 mg/dL 1, 2
For pediatric patients: Use 5% dextrose with 0.45-0.75% NaCl, with the saline concentration adjusted based on serum sodium levels 1
Essential Electrolyte Additions
- Always add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to dextrose-containing fluids once renal function is confirmed 1, 3, 4
- This potassium supplementation is critical because insulin drives potassium intracellularly, and failure to replace it causes life-threatening hypokalemia 4
Pediatric-Specific Considerations
- For children, D10W (10% dextrose in water) may be used in adrenal insufficiency with DKA, specifically as D10NS (10% dextrose in normal saline) at 20 mL/kg during the first hour 1
- Pediatric patients require more conservative fluid management with dextrose-containing solutions to minimize cerebral edema risk 3, 5
Alternative Approach: Two-Bag Method
- The two-bag method allows simultaneous infusion of two IV bags—one with insulin and no dextrose, another with dextrose—enabling rapid titration of glucose delivery without changing insulin rates 6
- This method shortens time to DKA resolution (13.4 vs 20.0 hours) and reduces hypoglycemia risk compared to traditional single-bag approaches 6
- The two-bag technique is particularly useful in preventing hypoglycemia while maintaining adequate insulin delivery to clear ketones 6
Critical Pitfalls to Avoid
- Never delay insulin infusion while waiting to add dextrose—insulin must continue until ketoacidosis resolves, not just until glucose normalizes 1, 3
- Never add dextrose too early (before glucose reaches 250 mg/dL), as this worsens hyperglycemia and delays ketoacidosis resolution 1
- Never forget potassium supplementation in dextrose-containing fluids—insulin therapy without potassium replacement causes dangerous hypokalemia and cardiac arrhythmias 1, 4
- Never allow osmolality to decrease faster than 3 mOsm/kg/hour when transitioning to dextrose-containing hypotonic fluids, especially in children, as this precipitates cerebral edema 3, 2, 4
- Never use D50W in pediatric patients—it is too hypertonic and irritating to veins; dilute to D10W or D25W maximum 1