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Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes which affects 30 million people in the United States.¹ Each year, DKA is responsible for over 500,000 hospital admissions at an estimated annual healthcare cost of $6.76 billion.² The annual incidence of DKA admissions in the US is steadily rising, with approximately 220,340 admissions reported per year.²

DKA is characterized by a triad of high blood glucose, anion-gap metabolic acidosis, and elevated serum ketone concentration. The leading cause of mortality in children and adolescents with type 1 diabetes, DKA is responsible for approximately 50% of all deaths in diabetic patients under 24 years old.²

DKA is a condition of severe volume depletion, with a typical total body water deficit on presentation of approximately 6 liters in adults.² Therefore, one of the initial management priorities is to reverse hypovolemic shock and restore extracellular fluid volume through the administration of isotonic crystalloid. The American Diabetes Association (ADA) guidelines recommend normal saline at a rate of 15–20 ml/kg body weight per hour or 1–1.5 liters during the first hour.² This intervention helps restore intravascular volume, improve renal perfusion, lower blood glucose levels, and augment insulin sensitivity.^3,4

A recent retrospective cohort study by Piehl and Adejumo of over 1,900 adult DKA patients found that earlier initiation of fluid bolus significantly improved hospital outcomes. For every hour of delay in fluid administration, time to DKA resolution increased by 32 minutes and hospital charges rose by $1,112. Patients who received fluid within the first hour had significantly lower odds of requiring mechanical ventilation, while those who received fluids after two hours had more than double the odds of ventilation need.⁵ These findings underscore the importance of rapid fluid delivery in the initial phase of care.

Traditional methods for fluid resuscitation, including pressure bags and IV infusion pumps, are often too slow and inefficient to provide rapid reversal of hypovolemic shock, delaying the resolution of DKA. Rapid infusers such as the Belmont or Level 1 could help speed resuscitation but are often difficult to set up and require extensive staff training for competency.⁶ Improved techniques for administering a sufficient volume of fluid in the early minutes of care could improve patient outcomes in DKA. The following case from a large community hospital demonstrates the effectiveness of such a technique for rapid fluid resuscitation for a patient with severe diabetic ketoacidosis and hypotension.

Case Presentation

A 61-year-old known patient with poorly controlled diabetes presented to the emergency department with nausea and intermittent vomiting, elevated glucose, and generalized abdominal pain. The patient was noted to be lethargic with Kussmaul breathing, heart rate of 130, and blood pressure of 82/48 mmHg. Significant lab results included a point of care blood glucose of 455 mg/dl, venous pH 7.1, venous bicarbonate 8.8 mmol/l, anion gap 28, urinalysis showed the presence of 4+ ketones, beta-hydroxybutyrate 108 mg/dl, and Hemoglobin A1C 15%.

Given this presentation of severe DKA with hypovolemic shock, the ED team obtained IV access and began rapid fluid resuscitation to correct the hypotension.

After an initial bolus of 1000 mL of 0.9% normal saline using the LifeFlow rapid infuser the blood pressure and heart rate improved. However, the patient again became hypotensive, and a second liter of normal saline was given over approximately 5 minutes. The blood pressure improved to 105/65 mmHg, the heart rate decreased, and the patient became more alert. After the two fluid boluses, a repeat blood glucose check showed a significant reduction to 325 mg/dl. Once the potassium level was confirmed to be normal, an insulin drip was started.

Based on the improvement in blood pressure and mental status, admission to the intensive care unit was deemed unnecessary and the patient was admitted to the general ward. By hour 10, the patient met ADA criteria for the resolution of DKA, with a blood glucose level of 187 mg/dl, a bicarbonate level of 17 mmol/l, and an anion gap of 11. The patient was discharged home on the second day.

Discussion

Earlier fluid resuscitation speeds up the resolution of DKA and improves patient outcomes. For patients with mild to moderate DKA, the ADA-recommended rate of fluid resuscitation may be sufficient to begin reversing hypovolemia, though with traditional infusion pumps, this may be difficult to achieve. For severe DKA with hypotension, more rapid fluid resuscitation is required to restore blood pressure and reverse shock. Gravity infusion is too slow, and while the addition of a pressure bag can improve speed of infusion, this method requires constant attention to maintain a higher flow rate and may be insufficient to address hypotension quickly. Traditional rapid infusers are often complex to set up, require frequent training to use in critical situations, and are rarely used outside of trauma centers.

LifeFlow allows providers to infuse fluids much faster than traditional methods, facilitating quicker stabilization of patients in shock. With LifeFlow, a bedside clinician can infuse 500 mL of crystalloid in under 2 minutes, enabling providers to quickly reverse shock, reassess the patient immediately, and administer additional fluids or blood if necessary.

The findings from the recent study by Piehl and Adejumo reinforce the importance of rapid fluid initiation in the early phase of DKA care—not only for improving clinical outcomes, but also for reducing the need for intensive interventions and lowering overall hospital costs.⁵ For patients with hyperglycemic emergencies requiring rapid fluid resuscitation, particularly those presenting with hypotension, traditional methods of fluid delivery are often ineffective. LifeFlow allows providers to begin infusing fluids in seconds, quickly correcting the patient’s fluid deficit and speeding the recovery from DKA.