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ketoacidosis initial ringer solution or isotonic saline solution 0.9% is preferred. The optimal infusion rate is dependent on the clinical situation of the patient. Patients with extreme volume deficiency need about 1000mL/hr for the first 4 hours. Patients with less extreme volume deficit can be substituted more carefully, e.g., at a rate of 500mL/hr for the first 4 hours followed by 250mL/hr for the next 4 hours (14).

The guidelines of the German diabetes association recommend in patients with high risk for volume overload, e.g., heart failure, especially with concomitant oligo- or anuria, controlling volume therapy by central venous pressure. After primary infusion of saline solution (0.9%), the balance should have a surplus of less than 500 to 1000 mL/hr (Table 5) (3,11). In cases where sodium levels are initially already in the upper limit of normal one should change to an infusion of half isotonic sodium chloride or hyporosmolar electrolyte fluids. This regimen should be used initially, in cases where sodium levels are greater than 150mmol/L or if severe hyperosmolality (>320m0sm/L) is present.

As an alternative for saline an isoltonic ringer lactate solution can be used. The precondition is an intact oxidative metabolism. It contains about 130mmol natrium and 112mmol chloride per liter and thereby less than 0.9% saline, which contains 150mmol/L sodium and 150mmol/L chloride. Lactate blinds hydrogen ions and will be metabolized in cases where the oxidative metabolism is intact. Because of the content of lactate (27mmol/L) ringer lactate is lightly alkalizing. In cases of metabolic acidosis this can alleviate the bicarbonate-C02-buffer system.

To prevent hyperchloremia, especially in cases of oligo- or anuria, an electrolyte substitution with lower chloride concentration such as sodium is recommended (11).

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