dka

1. Pediatric CME on DKA
Fluids & Bicarbonate therapy

2. I.V. fluids in Treatment of DKA
• Crystalloids- prefered- For both resuscitation
& maintanence
• Colloids –not preferred

3. ISOTONIC HYPOTONIC HYPERTONIC
OSMOLARITY/SOLUTE
CONCENTRATION
Osmolarity is same
as that of serum
osmolarity
Osmolarity is
lower than
serum
osmolarity
Osmolarity is higher
than serum
osmolarity
Fluid shift across
compartments
No shift.stays in the
intravascular space,
it expands the
intravascular
compartment
shifts fluid out of
the intravascular
compartment,
hydrating the
cells
shifts fluid from the
cells into the
intravascular
compartment
examples 0.9 % NS, RL 0.45% NS. D5W 3% NS
Classification of crystalloids- based on solute content/osmolarity

4. Isotonic fluids in DKA
• Fluid of choice for resuscitation - 0.9 % saline.
• 10 mL/kg infused over 20-30 minutes.
• 20 mL/kg infused over 20-30 minutes in patients
with shock.
• Maintanence - keep account of ongoing losses if
any
• Correction of fluid deficit should be done over
the first 24 to 48 hours by ensuring positive fluid
balance

5. Average fluid requirements-
Maintanence & replacement
Average is 70 ml/kg
over 24 hr period

6. Hypotonic fluids in DKA
• Based on the patient’s hydration status, serum sodium
concentration
• Used after initial resuscitation with isotonic fluids.
• Especially when serum sodium levels begin to rise above
normal ranges.
• They correct cellular dehydration once the intracellular
plasma volume is fairly replaced.
.
• Eg 0.45 % saline
D5W – when grbs is less than 200 mg/dl & patient is still
in acidosis / hyperglycemia is corrected more than the
recommended range of 75–100 mg/dL per hour.

7. • Unbalanced crystalloids (no buffer-base)
-0.9% saline
• Balanced crystalloids (have buffer-base)
-Ringer lactate
-Multiple electrolyte solutions
Isolyte (BRAUN)
Plasmalyte (BAXTER)
Kabilyte (FRESENIUS KABI)
Balanced vs Unbalanced crystalloids
Lactate buffer
Acetate buffer

8. • Excess of usage
of unbalanced
crystalloid like
0.9 % normal
saline can lead
to
hypernatremia,
hyperchloremic
acidosis
PLASMA 0.9 % saline RINGER LACTATE
SODIUM 142 154 130
POTASSIUM 4 4
MAGNESIU
M
2
CALCIUM 5 3
CHLORIDE 104 154 109
LACTATE 28
SULPHATE 1
PHOSPAHTE 2
BICARBONA
TE
27
PROTEIN 13
Organic
acids
6
pH 7.4 5.7 6.4

9. When to stop i.v. Fluids ?
• Acidosis is resolved.
• Anion gap is normalised.
• Child is able to take oral feeds normally.
• Need not rely on a repeat plasma acetone
test.

10. Bicarbonate therapy in DKA
• In DKA ,Fluid and insulin replacement
reverses acidosis .
• Routine use of bicarbonate therapy is not
recommended.
• Bicarbonate therapy may cause paradoxical
CNS acidosis and rapid correction of acidosis
with bicarbonate causes hypokalemia .
• Indiactions of bicarbonate therapy a) shock
or coma, (b) severe acidosis (pH less than
6.9), (c) bicarbonate <5 mEq/L, (d) acidosis-
induced cardiac or respiratory dysfunction,
or (e) severe hyperkalemia.
• Dose -Sodium bicarbonate, 50 to 100 mEq
in 1 L of 0.45% saline infused over 30 to 60
minutes.( add 10 meq kcl)