fluid therapy with DKA?

[janine3&5]

Okay, long story short: Had a pt today with DKA in the ER, and our ER doc ordered a 2 L bolus of IV fluids (NS, then changed to d5ns after blood glucose was less than 250) along with insulin drip. Keep in mind that I'm a brand new nurse, but to me this made sense, the fluids would dilute the blood glucose, restore fluid losses from polyuria, increase circulating volume, and so increase tissue perfusion.

So the pt gets admitted, and the admitting doctor comes down to see the pt and absolutely flips out on me when she sees that the pt has over 3-4 hours had 2 L of fluid. "I can't believe you would have that wide open on a pt with DKA, what are you thinking? and on and on and on"

First of all, the ER doc ordered the bolus! I didn't question the order because it made sense to me.

I can handle being told when I'm wrong, but I want to know why so I can learn from my mistakes. So tell me, why shouldn't DKA pts get rapid infusion therapy? What is the normal first line treatment in the ER?

[KungFuFtr]

While we are on the subject...

I was helping one of my coworkers with her pt. The PT had a bs in the 900's. I was to obtain an ABG, however, the doc changed her mind and wanted me to draw a VBG.

Really, what is the difference (besides the obvious)?

[chare]

you might find the following articles helpful.

arterial blood gases

correlation of central venous and arterial blood gas measurements in mechanically ventilated trauma patients

abg interpretation

can venous blood gas samples replace arterial blood gas samples for measurement of base excess in severely injured trauma patients?

[Altra, BSN, RN]

So the pt gets admitted, and the admitting doctor comes down to see the pt and absolutely flips out on me when she sees that the pt has over 3-4 hours had 2 L of fluid. "I can't believe you would have that wide open on a pt with DKA, what are you thinking? and on and on and on"

It's hard to be new, and not be sure of what you know & don't know. It gets better.

Excellent info given in this thread re: patho & differential diagnosis. Tight glucose control is a hot-button issue. I commonly see insulin drips started for values over 250.

With some experience you might ask the admitting doc who has some serious issue with 2L of NSS on a 36-year old with no cardiac issues ... "can you tell me what your concern is?" (AKA "what are YOU thinking??")

It's hard to walk in the ER with a stubbed toe and not get a liter of NSS.

[canoehead, BSN, RN]

Just along the same lines we had a woman come in with a sugar of 1960, no radial pulse, no audible BP, +carotid pulse, GCS 10, pH 7.02, K 7.3

We started 2 big lines wide open, and got a radial pulse during the second litre. She started making urine after the 5th litre. As soon as she barely touched a normal K we started supplementing, and would have started sooner if she had peed.

If someone is young and healthy you can flood them with fluid until they start peeing, then back off. A very nontechnical measurement of dehydration is how much fluid they take before urinating, but draw off a set of bloodwork before you start. During some busy triage nights I've taken the 20-30yo diabetic/dehydration patients, drawn the blood and started the fluid. By the time the doc gets to them they have labs back and a couple litres in. Sometimes they can be discharged from triage if the cause of the high sugar is obvious.