Fluid resuscitation in DKA/HHS with CHF

[Mel grant]

I am fairly new to the ICU and needs some help with fluids. I had a pt who was in HHS but also CHF and COPD. Pt was in obvious resp distress, unable to lie back even slightly. States they have slept in a chair with their head on the kitchen table for the past few years and this is baseline for them. They were put on DKA protocol (do not know why) which is 4 liters of fluid and an insulin gtt along with Q1H BS and Q4H labs. I am concerned about the amount of fluid (normal saline) they got. Later in the shift they became hypotensive and were ordered another 1,000 ml normal saline bolus. CXR after the 4 liters did not show any pulmonary edema. My question is, is there a better fluid than normal saline? How do i prevent needing to intubate the patient? Would lasix defeat the purpose of the fluid boluses? What is the role of albumin for fluid resuscitation in CHF and HHS or DKA? Any help would be appreciated. Thank you

[Tegridy]

For DKA usually we give NS for bolis then switch to half NS then finally d5 1/2 once glucose less than 200 to floors gap. Protocols vary by hospital.

Diagnosis of chf is obscure. This could mean end stage with an EF of like 10%. Or just diastolic dysfunction grade 1. Or just chart lore.

Nontheless if the patient is dry and hypotensive you still give the fluid in the above situation and he deteriorated respiratory wise you bipap or Intubate so you can still give fluid.

Person above sounds like minute chf and they need the fluid anyway.

albumin isn’t helpful for most situations. Including the one above. It sounds good in theory but expensive and outcomes not any better.