After the initial reexpansion, 0.45% NS is used. In children whose serum osmolality is high, 0.9% NS should be continued until it has decreased toward normal (<315 mosm/L).2 After the initial resuscitation is completed, the calculated remaining deficit should be replaced over the next 36 to 48 h depending on the calculated or measured osmolality (>320 mosm/L or >340 mosm/L, respectively).8 Once the serum glucose level is between 250 and 300 mg/dL,25 intravenous fluids should be changed to 5% dextrose solution (D5) and 0.45% NS. Administration of glucose limits the decline of serum osmolality and reduces the risk of cerebral edema. Insulin should be continued even after dextrose infusion has been started because blood glucose levels are corrected more rapidly than ketoacidosis. As long as acidosis persists, insulin infusion should be maintained at the same rate. Blood glucose levels should be maintained at approximately 5 250 to 300 mg/dL,2,5 and urine output should be replaced hourly with 0.45% NS. Oral hydration may be started as soon as nausea and vomiting subside. Fluid resuscitation and correction of metabolic abnormalities should not be undertaken too rapidly in order that such complications as cerebral edema, hypoglycemia, and hypokalemia may be avoided.
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