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When you need to build up your team to handle the growing chaos at work, use Indeed Sponsored jobs. It gives your job posts the boost it needs to be seen and helps reach people with the right skills, certifications and more. Spend less time searching and more time actually interviewing candidates who. Check all your boxes. Listeners of this show will get a $75 sponsored job credit@ Indeed.com podcast. That's Indeed.com podcast. Terms and conditions apply. Need a hiring hero? This is a job for Indeed Sponsored jobs. Hey, Dr. Chapa, I have a patient to check out to you. Our new admit is 11 weeks pregnant and has hyperemesis with urine ketones. I ordered her to get D5Ns as her initial fluid bolus.
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Man, we have learned so much about IV fluid replacement. We've learned so much about hyperemesis. I mean, now we know the genes that at least have a significant, maybe not all, but a significant role in hyperemesis gravidarum. So at one point, maybe we'll have gene therapy for it or ways to block those specific signals. I mean, it's amazing. One of those signals has to do with insulin, like binding protein number seven. And there's. I mean, we've gone now to the molecular basis of this thing, which. Which no patient who's puking her guts out is interested in at the bedside. She just wants relief from this terrible, terrible, intractable nausea and vomiting and even her understanding of how to fix this thing. Guys, how long have we been figuring out hyperemesis? I mean, it's nothing new. It's been around forever. But yet, In January of 2026, out of a very reputable journal, the Lancet, there's a brand new review that reminds us that sometimes doing things the old historic way not only are outdated, but are just plain wrong. Now, let me just set up the stage here and let me just brag on my institution that trained me for a little bit. So back when I was a medical student, I feared this man on internal medicine. Actually, those two of them, Don Selden, who is immortalized still at Parkland, and the other was Daniel Foster. Dan Foster wrote the chapter in Harrison's Internal Medicine for DKA Management. All right, so that's who trained me as a medical student and as a resident, because both Dr. Selden, who was then retired but would still come in and torture, I mean, question the medical students. And Dr. Foster was definitely still there. All right, so Dr. Foster, who is a diabetologist, who taught me as a resident, is legendary because he goes back, guys, to the 1960s. That was not when I was there. Give me a break. All right? But when he was in training, actually, it was 1967. The Foster Protocol was actually the one that launched the idea that for patients who are ketotic. Now, keep in mind, this is not with hyperemesis. This has nothing to do with pregnancy. This was in internal medicine, mainly with DKA patients that you really did need to give them glucose because you could reverse their ketosis, like in under 10 minutes. That. That is the foster protocol for DKA, all right? And that's what from there, that was the foundation to all of the insulin protocols. That's Daniel Foster, Dan Foster, who taught me how to manage diabetes back in the day. A legend. Okay, now, those original experiments were absolutely physiologically correct. However, it's outdated when it applies to the resolution of ketosis and hyperemesis. Okay, now if you first ask a brand new intern or a medical student, hey, I got a patient who's ketotic, because obviously they're malnourished, right? And also have a component of dehydration that goes with that. How would you expect to clear their ketones? The most innate response would come out to go, well, surely they need glucose. I mean, their cells need substrate to make energy so they can switch over to the new pathway for energy and get away from ketosis. Right? And totally right. That makes physiological sense. However, it's not complete, nor is it accurate. So in this episode, I thought it was interesting because I just had this conversation a couple of days ago regarding hyperemesis gravidarium and how when I trained, you know, we gave one of the ways that we checked patient response wasn't just their vital signs and a resolution of their tachycardia for their fluid replacement. And it wasn't just a urine output, which we should check and should be at least 0.5 milliliters or 1 milliliter per kilo. That's, you know, as you check that. That urine output, make sure it's coming out well as a sign of. Of rehydration. But we also checked urine ketones. Okay, so we checked her urine ketones to go. Ah, the urine ketones have now cleared. I have fixed her. Well, do we still do that? Is following up on urine ketones still a thing? Now, let me just bust the bubble here. No, and I've had to change my whole mindset around this as well, because it was so entrained into me that if she's ketotic, we gotta make sure she's better by making sure her ketones are gone. That is not a thing anymore. So I'm gonna get into that. We're also gonna explain why lactated ringer or normal saline with the preference towards lactated ringer actually does remove ketones. It actually reverse ketosis just by hydration. And there's. There's true proven physiology of. Of how that works. We're going to get into that. So we're going to talk about IV fluids. We're going to talk about why dextrose, why adding D5 containing fluids is not a thing anymore in any guidance. Guys, it's not smfm. It's not acog, it's not Royal College. We should not immediately go to D5 normal saline or D5LR as the initial fluid resuscitation for any patient with hyperemesis. And it's not just the Wernicke issue that is a big deal. I mean, you do need thiamine replacement at least 100 milligrams per day initially. Then you can switch over to an oral protocol of like 50 to 100 milligrams up to three times a day once they're taking oral substances back and tolerating that. So, yes, that is true. I mean, the Wernicke issue is a big deal. But more importantly is a recognition that dextrose in IV fluids to reverse ketosis is just not necessary. Much to the chagrin of Dr. Foster. You know, may his. May his honor and his legacy continue to live on. I mean, he changed the field of diabetic ketoacidosis management. Dan Foster published that in 1967. So do you need dextrose to reverse ketosis for hyperemesis? No, you do not. LR or normal saline are preferred, with mainly. Most obgyns prefer lightated ringer. And we'll get into that in just a minute. So, again, I think I spoiled it a little bit because dextrose containing IV fluids are not necessary to clear ketoneuria in hyperemesis, and that is no longer considered any part of the guidance, at least for initial resuscitation. So if you do get a patient checkout from a trusty new intern, and it's point of reference, we're doing this in April, so brand new interns are just around the corner. But if you get a checkout that sounds. Oh, something very similar to this.
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Dr. Chapa, I have a patient to check out to you. Our new admit is 11 weeks pregnant and has hyperemesis with urine ketones. I ordered her to get D5Ns as her initial fluid bolus.
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That's where you would say, hold on there, sister. Cancel that right now. Take that iv. Block it from her arm. Do not give her dextrose containing fluids. We'll be right back.
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We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN no Spin podcast family. We really have come a long way in our understanding of IV fluids and ketosis and even how we fix how we can correct hyponatremia if our patient with hyperemesis has hyponatremia. Theoretically and historically the guidelines said we had to correct that very slowly because if you corrected it too fast it ran the risk of some CNS issues like central pontinemyolysis. But that never really panned out in clinical practice or in other data. That's more of a theoretical concern and that was actually just published in a systematic review and meta analysis in 2025 that actually being more aggressive in correcting serum sodium levels actually decrease mortality. They did better with no CNS issues. So if they have hyponatremia, it's okay to be cautious, but you can actually be more aggressive with that because we've learned more about this. Okay. So they would need 3% hypertonic saline and you can actually correct them a little bit quicker than what was theoretically thought would be safe. Okay. And, but, but we've all just goes to. To show that we've just come a long way in how we view fluid management and dehydration and ketosis specifically regarding pregnancy. Now since we're talking about pregnancy, of course, as women's healthcare providers, we, we gotta kind of stick on this issue of ketones. Okay? Because ketosis goes with dehydration. But ketones not only are not necessary for the diagnosis of hyperemesis gravidarium, but once you make that diagnosis, whether or not they are ketotic, you don't have to keep following that up to see if it clears. I had to learn this again because again, as I said in the intro, that was one of the things that we, that was our test of cure. She's no longer ketotic. So I have done something and while you can do that, that's fine if you want to check the box, but it's not necessary. That's not. Part of the overall management is make sure that her ketones are clear. You follow her clinically with resolution of tachycardia with maintenance of urine output at least 0.5 CCs per kilo per hour, 0.5 MLs per kilo per hour at least, or 1 milliliter per kilo per hour because good urine output means better volume status. Make sure their blood pressure normalizes and that just that they feel better. You do not need to check their urine ketones. That's a big point to take home. Now. If you take a look at ACOG's practice bulletin back in 2004, they described hyperemesis as intractable nausea and vomiting, signs of dehydration that had supportive criteria like ketoneuria, high urine specific gravity, electrolyte imbalances or a weight loss greater than equal to 5%. However, ketoneuria was listed as a sign of dehydration rather than a standalone diagnostic requirements on, say right now, you do not need ketones to be diagnosed with hyperemesis gravidarium. Okay? Also in the royal college, the RCOG's position also states that it's based on patients intractable nausea, vomiting and inability to keep things down. That can include weight loss and dehydration. But Ketoneuria is a supportive feature that may or may not be present. You do not need ketoneuria for a diagnosis of hyperemesis. Before we leave this whole thing of ketones and diagnosis in 2021, the Windsor definition, remember, this was an international consensus definition. So it's not just one country, it's international. That's now widely referenced. The Windsor definition quote. The Windsor definition no longer includes ketonuria as a diagnostic criterion, end quote. It just defines hyperemesis, guys, as we already talked about it, as persistent nausea and vomiting, obviously causing distress to the patient. Typically, it's at or under 16 weeks and generally has some contributory findings of dehydration, but those are ancillary and supportive, but not yet required for the diagnosis. All right, so neither ACOG, nor the Royal College, nor the 2021 Windsor definition include ketosis as a criterion for diagnosis. So if you don't need it for the diagnosis, why would you need it? To follow up for clearance. Okay, and so just to be clear, you don't need it for a diagnosis, nor do you need to follow up ketones as proof that she is improving. It's all clinical. Now that we've said that, let's move very quickly here, guys, because I don't want to belabor this and we're going to hopefully be done here very quickly. I just want to harp on the point that IV fluids and do matter here. And we got to know what we're ordering. D5 is not first line for hyperemesis. If you take a look at ACOG's 2024 Clinical Expert Series on the inpatient management of hyperemesis, we covered this when they came out. It states, quote, we aggressively rehydrate with up to 2 liters of IV crystalloid over 2 hours. Now, here it is, guys. Quote, a randomized control trial of rehydration with either 5% dextrose and normal saline or normal saline alone in the first 24 hours found no significant differences in the elimination of ketoneuria or other outcomes, including vomiting, resolution of electrolyte abnormalities, or length of hospitalization or duration of IV antiemetic therapy. Lr. Here it is, guys. LR solution is another option for initial fluid hydration and is what is used at our institution. Remember, these are the authors under this clinical expert series. LR is what's used at our institution due to decreased incidence of acute kidney injury when compared with normal or isotonic saline. End quote. So there it is. And they also go on to say that as a general rule, while you can do the urine output as a test of improvement as ccs per kilo per hour. The general rule is that you want to keep it at least 100mls per hour or more and keep the IV fluid at least 125 to 150mls per hour. So there it is. So that goes through that, that historic publication that said, you know what, you. You actually don't need D5 at all. You can actually clear it with normal saline. And since LR is more balanced and physiologic, plus it includes a little bit of potassium, most people prefer lactated Ringer. And that's also what we do as well. In the January 2026 Lancet review on this, that was by Nana et al, they explicitly state that dextrose containing fluids are not appropriate for two reasons. One, they don't contain adequate amounts of sodium for correcting the electrolyte disturbances like hyponatremia or hypochloremia. And of course, high concentration of dextrose. If somebody gets, you know, really gung ho and starts the D5 without giving them thiamine, they can precipitate Wernicke's encephalopathy. So for those two reasons, okay, the potential neurotoxic issue of Wernicke's and The fact that D5 normal saline just doesn't provide enough of what the patient needs. Dextrose containing fluids are just not considered first line. Okay? Now, as I mentioned a little while ago, I don't know if you use normal saline. We prefer lactated ringer, as most consensus statements say. And here's why. Lactated Ringer can clear ketones if they are present and why they can reverse the whole dehydration issue very quickly. So first of all, remember that IV fluids is more than just volume for the body. Obviously, they're not able to eat or drink anything. They're gonna get dehydrated. So volume restoration is good. We need that because the body needs volume. However, guys, remember the clinical pearl from our family medicine and intro medicine, folks, that volume restoration, guys, is amazing. It also reduce a sympathetic tone of the body, and so it reduces that issue of pancreatic response. So let's walk through this very quickly. Dehydration activates the sympathetic nervous system, which directly inhibits pancreatic insulin release. So if you're dehydrated, boom. You're going to shut off insulin release when you rehydrate, that decreases the sympathetic tone and response. So this removes the inhibition so that you can have Proper insulin secretion. Now this restored insulin secretion then suppresses lipolysis and that's how you get the resolution of ketogenesis. Is that amazing or what? So intuitively you're like, how am I fixing the whole ketotic issue if they're not getting any glucose? Because it has to do with the stress response of the body to dehydration. So LR without any D attached to it can absolutely help reverse ketogenesis. All right. Even small increases in endogenous insulin are sufficient to suppress the hormone sensitive lipase in the fatty tissue that helps this ketogenic pathway. Go nuts. All right, so by giving the patient rehydration, you are shutting off the ketogenic pathway. Amazing plus with improved hydration. Of course, you also help there clear urinary ketones because they can excrete better. So all of this has to do with the root guys of dehydration. Okay, dehydration, bad dehydration, bad dehydration causes pre renal physiology. That reduces your GFR and that gives you near complete tubular reabsorption of the filtered ketone bodies. So once you do volume replacement, that GFR kicks up. You can now excrete ketone anions like ammonium and so that helps you with the clearance of pathway. So it's amazing. LR without sugar can actually clear ketosis based on the foundational reversal of dehydration and its re and its effect on the pancreas, its effect on the vasculature, and mainly its effect on renal perfusion. Amazing. Now intuitively you'd also think, wait, lactate is kind of a base, so that's probably what's converting some of the ketones and the ketosis and the acidosis back towards normal. That does have some truth to it, but there's not enough lactate has a base as a substrate there to actually do that. It does help a little bit, but the majority of this has to do again with just regular hydration status versus the lactate burden on this, which is really small. All right, so yes, there is some anti ketogenic properties to lactate, that's a plus. But you're definitely not doing enough of that to reverse the ketosis. It's just the rehydration that works. The amount of lactate In a standard LR is like 28 milli equivalents per liter. That that's a very mild to modest effect. So yes, it's helpful. That's good. You check the box at least. I'm giving it a Little bit of, of lactate, but. But it's anti ketogenic contribution is a minor role in this part. All right, so again, very quickly, because this did come out in print in January 2026 with the Lancets article and we had this discussion with a friend recently, I think their protocol, not mentioning any names, but their hospital protocol still includes adding dextrose as their initial fluid resuscitation. And I was like, man, that's kind of old school. It makes sense and I get that, but it's just not necessary. Plus the patient really needs to have some thiamine, some B1 on board first to help prevent wernicke. All right, so before we get ready to switch gears here and just very quickly again, just touch just a little bit more on the hyponatremia issue, just a little bit because we've already talked about it. The take home message is you don't need D5. The take home message is LR or normal saline are the way to go with a preference towards lactate or ringer. The take home is you don't need ketones for a diagnosis of hyperemesis. And if you do have ketones, fine, but you don't have to be checking them, you don't have to be chasing them until they clear you. Follow the patient clinically, how are her vitals, how's her urine output, how are the electrolytes, have they been replaced? And above all, is she symptomatically better? Because during all this, of course, you're also giving antiemetics as necessary. I do want to remind everybody that 2024 episode that we have where we cover this clinical expert series. Very nicely done. And it also talks about the correction of electrolytes and things to watch for. So if you've got electrolyte issues, especially weird potassium levels, be careful with Zofran at least theory because Aldansetron can lead to QT prolongation. So you got to watch, especially if it's over 500 milliseconds because of the potential, of course, for throwing that into weird conduction things and torsods. All right, rare, rare. But. But yes, it is possible. Now very quickly, this whole thing on hyponatremia, I called your attention. I'll just post this on our show notes. We're not going to get into it, but there is a meta analysis and systematic review obviously from 2025. That is the AS paper A Y U S out of JAMA internal medicine. Surprising, surprising what they found. They're like, you know what everyone's so cautious with replacing sodium because we don't want to fry their brain. And the truth is, frying their brain is kind of rare. You can actually be more aggressive with this. And those patients had decreased mortality. Yeah, it's better. So this whole demyelination issue is just wasn't seen. So now the new term is osmotic demyelination syndrome, or ords, or central pontiomyolysolysis. However you want to talk about it. This osmotic demyelation syndrome, I'm not saying it doesn't exist. It absolutely does. It just seems to be rare. And we can absolutely be more aggressive with correction of sodium defects, especially in our OB population that in general are younger and otherwise healthy. All right, this is going to be a quick one. Just a good reminder about IV fluid therapy being true to our mission to let you know what's in print, because J January 2026 as a Lancet is that nice review. And then because of the conversations that we had literally in the last couple of days, you know, we not. We had a women's health symposium and somebody presented on this, and urine ketones was a question that I raised on this. And then again, a good friend from an institution said, yeah, I think, you know, T5 is still kind of what we're doing as first line. And I thought this was important enough to put out as a message on the show that, you know, you do you, man. You do you. But dextrose containing fluids are no longer considered first line by any major society or professional organization. There's plenty of reasons that you can do LR or normal saline with restoration of normal hydration and volume status without the risks and the necessary issue of D5. Okay, so in summary, ketoneuria in hyperemesis is a marker of dehydration. Yes, starvation is part of that, but it has to do with dehydration in this context, because these patients aren't dka. Right? The ketosis of starvation with hyperemesis is different than the ketosis of dka. Those are completely different processes there. Same characteristics, different processes there. So adding dextrose to the IV fluid does not accelerate the clearance, nor is it required as a way to improve them very quickly. Just lactated ringers are almost saline. Second, you don't have to chase down ketones in the urine. Third, maintain urine output. And then number four, yes, you can actually be a little bit more aggressive with a correction of hyponatremia. Although I want to be very clear here, guys, this systematic review, meta analysis kind of shook the intro. Medicine, family medicine world with their hyponatremia correction because, like man, it seems to be pretty safe. And they die less if you do that without risking CNS issues. Although formal guidelines have not caught up. All right, so I'll be very clear. Formal guidance still stay. You got you want to watch your millie equivalents per liter, you know, for the first 10 to 12 hours. Do that slowly. That's the traditional guidance. Although that is changing quickly. Why, kids? Because medicine moves fast. As always, we're thankful for you. We're glad you're part of our podcast family. We've talked about hyperemesis, gravidarium, IV fluids, dextrose and ketones. We'll see you on the next episode of the OB GYN no Spin podcast. Michael, let's take it home.