Correction of fluid loss with intravenous fluids

Role of fluid therapy

Replacement of extravascular and intravascular fluid
losses initially for achievement of hemodynamic
stability then replacement of the total water deficit
over a period of 24 hours
Replacement of electrolyte losses specially potassium
loss
Reduction of hyperglycemia, hyperosmolarity and acidosis
Improvement of the renal perfusion leading to increased
urinary excretion of glucose and hydrogen ions

The rate of fluid administration depends on

o Degree of severity of dehydration which can be assessed
by clinical manifestations of dehydration and
calculation of the effective plasma osmolarity
o Age of the patient
o Cardiac and renal function of the patient
Choice of type of fluid therapy
Isotonic fluids are preferred in the initial management of
DKA
o Crystalloid isotonic fluids are used as normal saline
0.9% (NaCl) or Ringers lactate during the first hour
o Isotonic fluids are used even in patients with high
serum osmolarity because these fluids are still
hypotonic in comparison to the extracellular fluid of
the patient
o The subsequent choice of fluid therapy depends on the
:
State of hydration , level of serum electrolytes ,
and urine output
o isotonic fluids should be replaced by hypotonic
fluids in the following conditions:
 1. restoration of the normal hemodynamic stability
(euvolemia) in the form of within average blood
pressure , pulse , urine output and mental state
2. normal or high serum osmolarity which exist in the form
of :
corrected serum sodium > 150 meq/L
calculated effective plasma osmolarity > 320 mOsm/kg
Hypotonic fluids as( half-tonic saline 0.45%) are used
from the start when the serum osmolarity is ver high as
in the following conditions:
When the corrected serum sodium exceeds 150 meq/L
When the calculated effective plasma osmolarity exceeds
320 mOsm/kg
o Isotonic fluids should be replaced by hypotonic
fluids in these conditions because osmotic diuresis
caused by uncontrolled hyperglycemia is
characterized by loss of water exceeding loss of
sodium leading to more increase in plasma
osmolarity which is aggravated by continuous
administration of isotonic saline

5% Glucose solution or mixture of 5% Glucose solution + half-tonic

0.45% NaCl (simultaneous or alternative in case of severe
dehydration) is used when the blood glucose falls below
250 mg/dl due to the following causes :
o Maintain blood level of glucose in the range of 150-200
mg/dl to allow continuous administration of insulin to
correct ketoacidosis without causing hypoglycemia
o Prevent development of cerebral edema which can result
from rapid reduction of the blood glucose
Ringers lactate can be used to avoid development of
hypercholeremic acidosis which occurs with different
types of saline (due to low chloride content)
 Protocol of fluid therapy
Calculation of the total body water deficit (TBW deficit) from the
following formula
TBW deficit = 0.6 x wt(kg) x [1140/serum sodium]
The fluid deficit in the average adult is about 100 ml
/kg of the body weight = 5-8 L
1-2 L isotonic saline 0.9% are given during the 1st
hour with at least 1 L over the 1st 30 minutes
After the 1st 2 L , the patient should be evaluated as
regard the state of hydration , level of serum
electrolytes esp. sodium and urine output
This evaluation will decide the type of fluid therapy
During the 2nd hour , 1 L isotonic or hypotonic saline
is given
During the 3rd and 4th hours , 500 ml- 1L is given per
hour
The total amount of fluids in the 1st 5 hours is 3.5-5
L
During 6th-12th hours , 500 ml- 1L is given per hour
The fluid therapy should be shifted into 5% glucose
solution when the blood glucose
The total amount of fluid therapy required in the 1st
24 hours is about 6-12 L
The duration of intravenous fluid therapy is 48 hours