(DKA) Fluid Therapy

The absolute or relative lack of insulin starts a cascade of events that leads to hyperglycemia with resultant dehydration, electrolyte abnormalities, and acidosis. The latter results in part from intracelular hypoglycemia leading to the need to use other substrates for energy production. Besides evaluation and treatment of the precipitating cause, treatment is aimed at restoration of normal physiology and avoidance of complications of therapy. One can use potassium chloride instead of acetate, however, these patient's invariable develop a hyperchloremic acidosis since they typically receive large quantities of Normal Saline (NS) (154 mEq/L) which contains chloride as well as sodium. Over time they will excrete the chloride load, but there is really no reason to give them even more chloride when they need to make bicarbonate. The liver will convert the acetate to bicarbonate helping the patient correct their acidosis, while doing this more slowly than would occur with bicarbonate administration.

Therapy can be divided into the following areas:

• Fluid Therapy and Electrolyte Therapy:
  IV Fluids #1: NS + 20 mEq/L potassium phosphate + 20 mEq/L potassium acetate IV.
  IV Fluids #2: D10 NS + 20 mEq/L potassium phosphate + 20 mEq/L potassium acetate IV.
• Insulin Therapy
  Insulin infusion at 0.1 units/kg/hr.
• Ongoing management - The Two Bag Method
  • Serum glucose every hour in addition to bedside glucose monitoring.
  • Serum electrolytes and calcium, ABG or VBG every two hours X3.
  • Follow the Two Bag Protocol Sliding Scale for ongoing fluid management.