Friday, April 21, 2017

Fluid Choice in DKA

The Original Kings of County - By Hernandez R - April 19, 2017
..."Diabetic ketoacidosis is one of the diseases for which emergency physicians are expected to have a plan to quickly put into action. The basics should be familiar: Manage the patient’s ABCs, place an IV, put the patient on a monitor to check vitals frequently, and start with an intravenous fluid bolus. There are nuances beyond what is described here, of course (frequent glucose monitoring, adding dextrose once the patient’s blood glucose reaches 200-250 mg/dl, and the like). But our focus will be on that critical first intervention: The choice of IV fluid.
There is a consensus among endocrinologists and emergentologists that the first and most critical intervention in DKA is fluid resuscitation. Different guidelines point to normal saline (0.9% saline solution, aka NS) as the initial fluid of choice. Hydration should initially proceed rapidly at a rate of 1-1.5 liters over the first hour to support hemodynamic functions (e.g., kidney and brain perfusion). The rest of the fluid is meant to replace what was lost from the intracellular and interstitial compartments and should be given over the next 24 hours. [ Lately, some researchers have sought to compare balanced saline solutions (Plasma-Lyte, lactated Ringer’s, and others) to normal saline in DKA, because there is no data showing that NS is truly the best choice. This is an especially salient issue if you are managing DKA patients who are boarding in the Emergency Department. We will not be discussing colloids and hypertonic solution..."