Published online Aug 15, 2026. doi: 10.4239/wjd.121563
Revised: June 9, 2026
Accepted: July 2, 2026
Published online: August 15, 2026
Processing time: 131 Days and 11.5 Hours
Diabetic ketoacidosis (DKA) requires rapid fluid resuscitation; however, current guideline-based protocols depend on static assessments of volume status. We need a new fluid resuscitation protocol to correct DKA and alleviate the DKA-related symptoms such as fever, mania, inflammation and depression caused by the imbalance of water and electrolytes.
To evaluate whether non-invasive haemodynamic monitoring with the ultrasonic cardiac output monitor (USCOM) integrated with passive leg raising can optimise fluid resuscitation in adults with DKA without compromising metabolic recovery.
We undertook an embedded, comprehensive review of studies on rehydration for DKA and a proof-of-concept in an emergency department in Jiangsu, China. In the first stage, adults with DKA were allocated (1:1) to USCOM-guided resuscitation or sham USCOM monitoring. In the intervention group, additional fluid boluses (250 mL crystalloids over 15 minutes) were given only when stroke volume increased by ≥ 10% during passive leg raising. The primary outcome was net fluid balance at 24 hours, 48 hours, and 72 hours. Secondary outcomes included urine output, length of hospital stay, glycaemic control, urinary ketone clearance, and adverse events. In the second stage, we systematically retrieved clinical studies on fluid resuscitation in DKA from the PubMed database and performed an in-depth analysis of the available evidence. We conducted a systematic review of the evidence to increase externality validation and generalization.
Fifty participants with a mean age of 48.0 ± 16.2 years (42% males) were enrolled. Compared with the control group, the USCOM-guided group exhibited a significantly lower net fluid balance at 48 hours (-1246.8 mL; P = 0.007) and 72 hours (-1759.5 mL; P = 0.001), associated with greater urine output in the first 24 hours (+952.6 mL; P = 0.002). Length of hospital stay was reduced by 1.92 days (P = 0.034). Non-significant differences were observed between groups in blood glucose trajectories, urinary ketone clearance, or adverse event rates. The systematic review identified 20 clinical studies investigating fluid resuscitation in DKA, involving 8402 patients. These included 1 randomized controlled trial, 3 observational studies, 1 nested cohort study, and 15 cohort studies, pro
Dynamic, non-invasive haemodynamic monitoring is a feasible approach to optimising fluid resuscitation for DKA and supports the need for larger multicentre trials.
Core Tip: Diabetic ketoacidosis requires urgent fluid resuscitation, yet standard protocols only adopt static volume assessment. This Chinese emergency department mixed-methods study develops a non-invasive doppler strategy combining ultrasonic cardiac output monitoring and passive leg raising for personalised adult diabetic ketoacidosis rehydration. Compared with guideline routine care, it safely lowers 72-hour net fluid balance and hospital stays without harming metabolic or renal recovery. Feasible at bedside, it reduces iatrogenic fluid overload and lessens resource pressure in under-resourced emergency settings without invasive monitors.