Dear Dr. Steele:
We have been using the following approach for over 20 years =
any untoward problems.
We administer 10-20cc/kg bolus over one hour (not exceeding 1L). =
we infuse =BD NS with 20-40 mEq/L K as Acetate or Acetate + =
correcting the deficit over 48hrs for serum Na <150 mEq/L or over 72hrs =
Na > 150. We add 5% Dextrose when serum glucose is < 500mg/dL. We do =
replace urine losses except in DI.
Reuben D. Rohn
From: Dale Steele [SMTP:[log in to unmask]]
Sent: Wednesday, March 11, 1998 2:14 PM
To: [log in to unmask]; [log in to unmask];
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Subject: Initial fluid management in severe DKA
We recently debated the initial fluid management of
presenting with severe diabetic ketoacidosis (DKA). A hypothetical
--an 8 month-old male infant with new onset DKA, a heart rate of 190
poor peripheral perfusion, but not hypotensive. Glucose 1054 mg/dL,
(arterial) 7.03, pCO2 10, serum Na 145 meq/L, chloride 113,
HCO3 less than 5, BUN 35 mg/dL, creatinine 1.7 mg/dL, lactate 2.1
Discussion centered around two issues.
I. Which components of the evaluation predict intravascular
depletion (compensated shock) in the setting of concurrent acidosis
II. What are the risks, if any, of rapid infusions of normal
in pediatric patients with severe DKA? Which patients need rapid
of intravascular volume? How much?
Which respect to these issues, how would you respond to the
Capillary refill time is primarily increased secondary to acidosis
not imply compensated shock in this setting.
Tachycardia results from increased epinephrine as part of the excess
counter-regulatory hormones, and therefore may not imply volume
A normal lactate implies the absence of significant intravascular
depletion, therefore, if lactate is normal, a normal saline bolus
The rapid initial decline in serum glucose associated with improved
perfusion increases the risk of cerebral edema.
Too vigorous initial fluid resuscitation with "isotonic" fluids
the ED predisposes patients with DKA and other hyperosmolar states
I look forward to your learned replies...
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Dale Steele, M.D. Assistant Prof. of Pediatrics
Pediatric Emergency Medicine Brown University
Potter 212, Rhode Island Hospital Voice: (401)444-6236
593 Eddy St. Fax: (401)444-4569
Providence, RI 02903 USA
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