I disagree with this approach from a critical care stand point. a 250 mL bolus is about worthless for intravascular expansion, a 500mL isn't much better, for dka/hhnk yeah they take less fluid than their non-renal counterparts but they still need fluid, typically in the liters range (not the 8-12 a hhnk may need, but easily 2-6L). but keep in mind dka pts also have huge insensible losses from their increased respiratory drive from the acidosis, and even more so if it is infection induced. honestly what's the worst risk associated with inducing a little fluid overload in these pts? pulm edema? hypercloremic acidosis?
the septic pts I have no qualms about giving them 20-40ml/kg fluid and do so frequently and have yet to push them into so far I had issues oxygenating them. since we're in the critical forum this goes with the assumption you're in a critical care floor, it goes without saying theyre being monitored closely. being CC trained I'm kinda a **** of get off the pot kinda guy, the only time I give less than a liter bolus is in the ESRD who also has significant cardiomyopathy, but if they're hypotensive, most likely they'll still get bolused a liter at a time, and anecdotally, we don't have issues with respiratory status using an agressive approach. now we could argue the risks of a hypercloremic acidosis, but that's of little concern to me when they're hypotensive.
ultimately we're on the same page I think, reevaluate the pt frequently.
I think we are on the same page.
But, Last night, I consulted on an ESRD patient in DKA. He presented with N/V for one day.
Here are his initial labs:
Na 138, K 5.1, Cl 79, CO2 39, BUN 65, Creat 8.5, Glucose 617, Positive serum ketones.
ABG 7.45/53/83/ 94%
His initial BP was 95/60 (which is very low for this Dialysis patient). He normally run blood pressures of 150-170's/80-90's.
So from the labs, he has a huge metabolic Anion gap of 30 and also a concurrent metabolic alkalosis, plus a small Respiratory acidosis.
Guess how much fluid he required?? Three boluses of saline 500 cc ( or just 1.5 liters). By the way, he weighs about 80 kgs. His Blood pressure came up nicely with this to 130/80.
His gap quickly closed with this small amount of fluids and the insulin drip. I dialyzed him this morning, and he weighed in above his dry weight and was hypertensive before the treatment. Basically, if he would have gotten more fluids, it would have been fine, but more for us to ultra filtrate later during dialysis. I try to aim for the smallest, yet most effective volume.
But yes, I think we are on the same page. You can give fluids to dialysis patients!!