Children with DKA will have lost a great deal of sodium, whatever their initial measured plasma sodium. Normal saline is the correct initial fluid. The principles of fluid management outlined above work as well for DKA as for any other cause of dehydration. However, because of the hyperglycaemia it is often best not to give dextrose initially. Thus, having calculated deficit, maintenance, and 24-hour requirement, this can initially be given all as normal saline, switching to 0-45% saline or 0-18% saline with dextrose once the blood sugar has fallen. With the osmotic diuresis, which will persist until the blood sugar falls, calculated fluid requirements will be an underestimate and ongoing fluid replacement should be recalculated 4 hourly to take into account excess fluid losses. Potassium should be added to the fluids (20-40 mmol/l initially) once a urine output has been confirmed. There is a loss of potassium in DKA and, additionally, the use of insulin will drive potassium into cells, further lowering the plasma potassium.
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