A 23-year-old woman with a 12-year history of type 1 diabetes mellitus is hospitalized with diabetic ketoacidosis. On admission, her blood pressure is 80/60 mm Hg, pulse is 120/min, and respirations are 28/min. She weighs 60 kg (132 lb). Her oropharynx is very dry. Abdominal examination shows diffuse tenderness without guarding or hepatosplenomegaly. The remainder of her physical examination is within normal limits.
Her clinical status improves significantly with intravenous (IV) fluids and insulin. In the first 2 hours, she receives 2 liters of isotonic saline (NS), and this is later changed to 1/2 NS with potassium chloride (KCl) at 250 mL/hr. The patient is also receiving IV regular insulin infusion. Her blood glucose declines steadily to 188 mg/dL after 6 hours of treatment. She states that she is feeling better but still feels very nauseous.
Laboratory results are as follows:

Which of the following is the most appropriate fluid management for this patient?

Question

A 23-year-old woman with a 12-year history of type 1 diabetes mellitus is hospitalized with diabetic ketoacidosis.  On admission, her blood pressure is 80/60 mm Hg, pulse is 120/min, and respirations are 28/min.  She weighs 60 kg (132 lb).  Her oropharynx is very dry.  Abdominal examination shows diffuse tenderness without guarding or hepatosplenomegaly.  The remainder of her physical examination is within normal limits.
Her clinical status improves significantly with intravenous (IV) fluids and insulin.  In the first 2 hours, she receives 2 liters of isotonic saline (NS), and this is later changed to 1/2 NS with potassium chloride (KCl) at 250 mL/hr.  The patient is also receiving IV regular insulin infusion.  Her blood glucose declines steadily to 188 mg/dL after 6 hours of treatment.  She states that she is feeling better but still feels very nauseous.
Laboratory results are as follows:

Which of the following is the most appropriate fluid management for this patient?

Quizplus · Accepted Answer

11ec193a_96c3_e29f_853d_aff875297e4e_MD0002_00 Treatment of diabetic ketoacidosis (DKA) requires attention to fluid and electrolyte management, prompt intravenous (IV) insulin therapy, and correction of precipitating causes. Patients typically have a 3-6 L fluid deficit, and isotonic saline (NS) infused over 1-2 hours is recommended to expand intravascular volume and improve tissue perfusion. Further fluid repletion depends on the patient's hemodynamic status and sodium levels. NS is recommended for patients with low serum sodium levels, but patients with normal to high sodium levels are given 1/2 NS. The serum potassium levels at presentation may be normal or high despite a significant total body potassium deficit (400-500 mEq/L). Potassium levels decline rapidly after institution of fluids and insulin. Therefore, 20-30 mEq/L of potassium are added to each liter of IV fluid replacement to maintain serum potassium between 4-5 mEq/L. Potassium replacement is withheld only when the serum potassium levels are >5.2 mEq/L (Choice D). (Choices A and B) Once the blood glucose reaches <200-250 mg/dL, patients should be given dextrose-containing fluids to decrease the risk of hypoglycemia. However, IV insulin should be continued to ensure resolution of ketosis. Educational objective: Patients with diabetic ketoacidosis should receive high-flow intravenous (IV) fluids and IV insulin. Isotonic saline (NS) is preferred initially, with eventual switching to 1/2 NS. Once blood glucose is <200-250 mg/dL, dextrose should be added to the fluids, but IV insulin should be continued. Potassium should also be added to fluids unless serum potassium is elevated (>5.2 mEq/L). __________ References: Management of adult diabetic ketoacidosis. (http://www.ncbi.nlm.nih.gov/pubmed/25061324)

A 23-Year-Old Woman with a 12-Year History of Type 1