酮酸中毒補充體液 2016.01.19.15.52 DKA fluid therapy

參考資料 uptodate Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment

第一個小時, 補充大約 1000CC 等張生理食鹽水. 不要超過 50cc/kg.
Glucose 每上升 100. Na 濃度往上加 2. 例如血糖 300. Na 135. 校正後的Na= 135+4= 139
如果校正後的 Na < 135. 每小時給 250-500cc 等張食鹽水.
如果校正後的 Na 正常或略高. 給予 half saline 250-500 cc/小時.
鈉鉀都會增加血中滲透壓. 所以如果補充 K 的時候, 也可以考慮給予 half saline.

Fluid replacement — In patients with DKA or HHS, we recommend vigorous IV electrolyte and fluid replacement to correct both hypovolemia and hyperosmolality.

Fluid repletion is usually initiated with isotonic saline (0.9 percent sodium chloride). The optimal rate of isotonic saline infusion is dependent upon the clinical state of the patient. Isotonic saline should be infused as quickly as possible in patients with hypovolemic shock. (See "Treatment of severe hypovolemia or hypovolemic shock in adults".)

In hypovolemic patients without shock (and without heart failure), isotonic saline is infused at a rate of 15 to 20 mL/kg lean body weight per hour (about 1000 mL/hour in an average-sized person), for the first couple hours, with a maximum of <50 mL/kg in the first four hours (algorithm 1 and algorithm 2) [1].

After the second or third hour, the choice for fluid replacement depends upon the state of hydration, serum electrolyte levels, and the urine output. The most appropriate IV fluid composition is determined by the “corrected” sodium concentration. The “corrected” sodium concentration can be approximated by adding 2.0mEq/L to the plasma sodium concentration for each 100 mg/100 mL (5.5 mmol/L) increase above normal in glucose concentration (calculator 1). If the “corrected” serum sodium concentration is less than 135 mEq/L,then isotonic saline should be continued at a rate of about 250 to 500 mL/hour [1]. However, if the “corrected” sodium concentration is normal or elevated, then the IV fluid is generally switched to one-half isotonic saline at a rate of 250 to 500 mL/hour in order to provide electrolyte-free water. The timing of one-half isotonic saline therapy may also be influenced by potassium balance. Potassium repletion affects the saline solution that is given, since potassium is as osmotically active as sodium. Thus, concurrent potassium replacement may be another indication for the use of one-half isotonic saline. (See 'Potassium replacement' below.)

當血糖降低至 200(DKA) 或 250-300(HHS) 補充糖水和生理食鹽水.

We add dextrose to the saline solution when the serum glucose reaches 200 mg/dL (11.1 mmol/L) in DKA or 250 to 300 mg/dL (13.9 to 16.7 mmol/L) in HHS. (See 'Intravenous regular insulin' below.)

適當補充水分可以改善高滲透壓狀態, 加強 insulin 療效.
心臟腎臟功能不良的患者要更加強監測, 避免補充過多水分.
治療目標是 24 小時內將預估的缺乏體液電解質補充完畢
不要將滲透壓降太快. 以免引起腦水腫.

Adequate rehydration with correction of the hyperosmolar state may result in a more robust response to low-dose insulin therapy [11,12]. Adequacy of fluid replacement is judged by frequent hemodynamic and laboratory monitoring (see 'Monitoring' below). In patients with abnormal renal or cardiac function, more frequent monitoring must be performed to avoid iatrogenic fluid overload [9,10,12,15-18]. The goal is to correct estimated deficits (table 2) within the first 24 hours. Osmolality should not be reduced too rapidly because of concern that this may cause development of cerebral edema. (See 'Cerebral edema' below and"Treatment and complications of diabetic ketoacidosis in children", section on 'Cerebral edema'.