A patient with diabetic ketoacidosis is often moderately to severely dehydrated. Fluid resuscitation is an essential part of management.
Patient selection: diabetic ketoacidosis
Peripheral venous access is sufficient for most patients. If a central line is deemed necessary, then a short-term femoral access may have benefits, especially if the patient is delirious or has hemodynamic instability.
Initial fluid replacement is with isotonic saline or lactated Ringer's solution.
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Adult
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Pediatric
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initial (no more than 2 hrs)
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1.0 to 1.5 L per hour
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15 to 20 mL per kg per hr
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followed by
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250 to 500 mL per hour
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4 to 8 mL per kg per hr
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once glucose below 250 mg/dL
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150 to 200 mL per hour
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2 to 4 mL per kg per hr
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The amount of fluid to administer depends on hemodynamic status, state of hydration, serum electrolyte concentration, and urinary output.
If the corrected serum sodium is high, then 0.45% saline can be used.
Once the patient has been rehydrated and the blood glucose is below 250 mg/dL, then the patient can receive 0.45% saline with 5% to 10% dextrose plus insulin. This is continued until the acidosis has resolved.
Euglycemic diabetic ketoacidosis can receive dextrose solutions sooner since hyperglycemia is not the issue.
The patient should be monitored carefully while receiving fluid.
Patients at risk for fluid overload:
(1) end-stage renal disease with anuria or oliguria
(2) congestive heart failure
Cerebral edema is a risk if the tonicity of the blood falls too rapidly or if the intravenous fluids are hypotonic.
Resuscitation with 0.9% or 0.45% saline (rather than lactated Ringer's) may be followed by non-anion gap metabolic acidosis (NAGMA).
