Water and Salt Replacement in DKA

• Water and salt deficits must be replaced. IV or oral fluids that may have been given before the child presents for treatment and prior to assessment should be factored into calculation of deficit and repair (A).
• Initial IV fluid administration and, if needed, volume expansion should begin immediately with an isotonic solution (0.9% saline or balanced salt solutions such as Ringer’s lactate). The volume and rate of administration depend on circulatory status, and where it is clinically indicated, the volume is typically 10 to 20 ml/kg over 1 to 2 hours, repeated if necessary (E).
• Use crystalloid (C).
• Subsequent fluid management should be with a solution with a tonicity ≥0.45% saline (C):
This can be achieved by administering 0.9% saline or balanced salt solution (Ringer’s lactate or 0.45% saline with added potassium) (E).
Rate of IV fluid should be calculated to rehydrate evenly over at least 48 hours (E).
• In addition to clinical assessment of dehydration, calculation of effective osmolality may be valuable to guide fluid and electrolyte therapy (E).
• Because the severity of dehydration may be difficult to determine and can be overestimated, infuse fluid each day at a rate rarely in excess of 1.5 to 2 times the usual daily requirement based on age, weight, or body surface area. Urinary losses should not be added to the calculation of replacement fluids (E).