fluid therapy with DKA?

  1. 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?
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  2. 15 Comments

  3. by   NinaC
    Janine,

    Bolusing the patient with 2 Liters of NS is a common order for DKA basically to dilute the glucose. It is what is ordered commonly in the ER. If the attending had questions about the order and did not want to listen to your explanation, then you should have reffered her to the ER doctor or perhaps you could have asked the attending why the patient should not be bolused with the saline over that period of time.
  4. by   CEN35
    first you did nothing wrong............ second............clearly the attending/admitting doc was a moron. unless.........this person had a hx of chf/pulmonary edema, a-fib/flutter or recent cabg.


    let's start with many of the needed results and hx to treat properly. i'll answer tomorrow sometime.

    #1 - blood glucose initially was?
    #2 - etoh use?
    #3 - hx of dm yes or no?
    #4 - abg's - if his bs was really high and a true dka, then ph is crucial.
    #5 - the remainder of the chemistries +amylase+lipase+hfp are important, with a cbccdiff, chest x-ray, and ekg also.

    assuming he is/was a true healthy dka......the nss bolus is fine no problem there. it's not to dilute the bs, it's to rehydrate the intervascular system......because these people are severely dehydrated, from polyuria, secondary to the kidneys attempt to spill glucose.
    thiamine 100mg im or iv........because thiamine is a co-enzyme that allows the brain to use glucose.....if they are thiamine deficient anything else you do is futile. if the person is an excessive user of etoh, and may be the cause of this event...you may need to add an amp of mvi to the bag also. make sure nothing is given im if you think it is etoh related. if it is etoh related you want to avoid any im injections, if the liver is screwed up a little im shot could cause a large bleeding problem.
    then most like to start an insulin drip at 10 units per hour. some also like to give 10 units iv push, prior to starting the drip. why 10 units? the liver can only metabolize about 10 units an hour. anything more than that, is just asking for the patients blood sugar to take a dive to "0", after the drip is stopped. it dont get any worse than that!
    keep and eye on the one touches/accu-checks........stop the drip when it hits about 250. the other thing you want to do........is make sure you get the potasium checked when it hits about 250.......of course it also depends where it is initially. with most dka's > 700 you can expect the k to be between 5.5 and 7.9. as the glucose drops........so does the k. if they are at 750 glucose and 5.5 k, the risk is for the k to drop too about 2.8-3.2 or maybe lower when the glucose hits 250, so you need to compensate for that. of course......usually the k is going to be high......depending on the glucose say 750-1000 probably the k will be about 6.8 to 7.9.
    the good side of this.....is by the time they hit a glucose of 250.....they should have a k about 4.5 -5.8, which is good.
    outside of that stuff.............the only other things needed, are to keep the body temperature up......which can drop (i've seen them as low as 31.7c in a 72 degree house, and watch for arrhythmias and the b/p if they are acidodic.

    once the glucose is about 250........then they can go ahead with the d51/2nss to get the rest of the tissues hydrated.....and keep him from bottoming out.......and your home free!!!
    Last edit by CEN35 on Aug 17, '01
  5. by   TI2Grr
    Janine Looks as if you did wonderfully.. The big thing here is making sure that you don't shift to quickly the patient is in acidosis and the most important thing is insuring his Ph changes occur slowly, thus you want to keep giving dextrose and maintain the blood glucose preferably above 200 or 250 so he/she doesn't crash on you, then presenting more problems. The important thing is watching Ph, and also Ketones in urine.. Hence you will be giving quite a lot of bolus, normally in a couple of different IV solutions, one probably being NS, and the other being a dextrose solution, and watching the shift occur from acidosis to a normal baseline.

    An important thing to realize here is that different strokes for different folks -- referring to Doc's here, and this shift can occur in a couple of different manners, initial phase of getting this person stabilized was done as normally seen by a lot of different facilities and also patients. Sounds like the intern didn't know what the heck was going on or didn't explain something else due to something seen in the patients lab values..

    Don't get frustrated.. You did well..
  6. by   ALISHAJO
    [QUOTE]Originally posted by janine3&5 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. 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. [QUOTE]

    I just had a patient like this yesterday --age 30's, IDDM with a sugar of 977, c/o abd pain. Vital signs stable (except for pain scale). Our ER Doc had me hang NS 1000 cc wide open- once blood sugar came back, then hung an insulin drip and we did frequent sugar checks. He was in ER for about 3 1/2 hrs and went thru 4 liters of NS- 3 wide open before he let me slow it down to 200/hr and add KCL in the last one. I questioned my ER Doc about this too but he said the patient was young and he could take it. (needless to say I monitored his vitals frequently and observed for changes in LOC- no changes)
    You did not mention the age range of your patient. That could be a concern. Also did the person have any other medical problems like kidney function problems, CHF,...ect...get the idea? Was the patient unstable in regards to vital signs or did the sugar come down too quickly? I know that it can cause more problems when it comes down too quickly....
    I don't think I would have accepted the 2nd doctor's comments so quickly that you had made a mistake!!! I would have addressed the 2nd doctor's comments with the fact that you are not the doctor and perhaps he/she needs to take it up with the ER Doc that took care of the patient. Surely, the ER Doc passed on that information when he/she called to get acceptance for admission.
    I would also like to see other comments and information about what is right or wrong with these scenerios...
  7. by   janine3&5
    I'm so glad to hear these replies; I got the same response from a nurse at work today that I talked it over with. My understanding of the pathophys was a little off, but glad to hear I didn't screw up.

    The pt was a 36 yr old F, Hx of DM (admittedly very non compliant, had been in a few weeks earlier with same problem), no other significant medical Hx. VS okay. Denied Hx of Etoh. Initial blood sugar wasn't that high; 303. So the Dx came from the other lab values; ketones in urine and ABGs out of whack. Honestly, I couldn't tell you much about the rest of the lab values except that nothing jumped out at me as being way out of range.

    I ran the first L of NS in wide open and had an insulin drip going at 7 U/hr. After 30 min the BS was 169, so I switched to D5NS. Kept the drip going at 7U. Then BS were to be done hourly.

    In better circumstances, I would know more about the labs on my pt. This was my second day on my own on the floor, and wasn't supposed to be my pt. I (along with a tech) already had 5 pts on our critical care side, but then the nurse working next to me got pulled to a trauma, so I got his 2 beds as well for about 7 hrs. We were slammed all day, so after I checked labs or orders, I dealt with them and then moved on. I kind of feel like I didn't really have time to critically think things through to really understand the big picture of what was going on with this pt, so when I had to deal with this doctor, I did doubt myself. Also, I literally did not have time to deal with her! She's someone who loves to make a scene and belittle the nurses, so to an extent, I wanted to just let it go. But as I said earlier, I want to learn, and I want to understand why I'm doing orders, that was the reason for my post. Although I could go on and on about this doctor and my crappy day!

    So thank you so much for your replies, that's what I wanted to know, and now I better understand the rationale for the treatment. You guys are good!






  8. by   CEN35
    what was the patients mental status like? how far out were the abg's?
    you said the sugar was 303? i guess it seems a little bizzare for them to dx dka with a blood sugar of 303? i would assume they were a&ox3, and most values were fine, or near fine. i also am kind of amazed that they started an insulin drip with a 303 bs. that can be corrected with insulin sc, and most often is until their bs > 500. the other thing is, my guess is that at 303, they were not all that dehydrated......maybe thats why the doc went off?
    the other thing to remember is, while urine tests are good. most diabetics, pregnant women, people on diets spill ketones. most diabetics will have glucose in their urine also. what about the bun and creatinine, along with the urine sg?

    just a thought?
  9. by   janine3&5
    I was surprised too with the Dx with that BS. I asked another nurse about it, who said it was DKA because of the ketones and ABGs. The patient was oriented, but lethargic, sleeping most of the time and slow with responses. As far as the dehydration, pt was not able to urinate until after the second L of fluid. The ABGs, I only really glanced at the first set and saw the abnormals. I'm a new grad, so it takes me a little while to analyze the results to understand what I'm seeing, and now I couldn't even tell you what they were!


    Its very frustrating to me when things need to move so quickly that I don't have the time to understand the physiology and rationales, but I try to go home each night and research the things I've seen during the day that I didn't quite get. The nurses and docs are very supportive for the most part and are great at answering my many questions, but there's not always time to ask everything I want to know while at work. But despite this, I love the ER and I can definitely saying that I'm learning everyday.
  10. by   CEN35
    originally posted by janine3&5
    i was surprised too with the dx with that bs. i asked another nurse about it, who said it was dka because of the ketones and abgs. the patient was oriented, but lethargic, sleeping most of the time and slow with responses. as far as the dehydration, pt was not able to urinate until after the second l of fluid. the abgs, i only really glanced at the first set and saw the abnormals. i'm a new grad, so it takes me a little while to analyze the results to understand what i'm seeing, and now i couldn't even tell you what they were!


    its very frustrating to me when things need to move so quickly that i don't have the time to understand the physiology and rationales, but i try to go home each night and research the things i've seen during the day that i didn't quite get. the nurses and docs are very supportive for the most part and are great at answering my many questions, but there's not always time to ask everything i want to know while at work. but despite this, i love the er and i can definitely saying that i'm learning everyday.

    thats all that matters then!!!!
  11. by   MassED
    Quote from 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?
    I see no problem with 2 liters of NS - that's part of the normal treatment in my mind - and if the doc orders more or at a slower rate due to cardiac issues, then I implement the changes. ER docs won't be thinking like hospitalists, which is fair that their priorities are different. Usually hospitalists, or whomever is admitting, will see them in an improved state. You should shrug that off. The middleman, or woman, is always caught in the middle, eh?
  12. by   MassED
    Quote from janine3&5
    I'm so glad to hear these replies; I got the same response from a nurse at work today that I talked it over with. My understanding of the pathophys was a little off, but glad to hear I didn't screw up.

    The pt was a 36 yr old F, Hx of DM (admittedly very non compliant, had been in a few weeks earlier with same problem), no other significant medical Hx. VS okay. Denied Hx of Etoh. Initial blood sugar wasn't that high; 303. So the Dx came from the other lab values; ketones in urine and ABGs out of whack. Honestly, I couldn't tell you much about the rest of the lab values except that nothing jumped out at me as being way out of range.

    I ran the first L of NS in wide open and had an insulin drip going at 7 U/hr. After 30 min the BS was 169, so I switched to D5NS. Kept the drip going at 7U. Then BS were to be done hourly.

    In better circumstances, I would know more about the labs on my pt. This was my second day on my own on the floor, and wasn't supposed to be my pt. I (along with a tech) already had 5 pts on our critical care side, but then the nurse working next to me got pulled to a trauma, so I got his 2 beds as well for about 7 hrs. We were slammed all day, so after I checked labs or orders, I dealt with them and then moved on. I kind of feel like I didn't really have time to critically think things through to really understand the big picture of what was going on with this pt, so when I had to deal with this doctor, I did doubt myself. Also, I literally did not have time to deal with her! She's someone who loves to make a scene and belittle the nurses, so to an extent, I wanted to just let it go. But as I said earlier, I want to learn, and I want to understand why I'm doing orders, that was the reason for my post. Although I could go on and on about this doctor and my crappy day!

    So thank you so much for your replies, that's what I wanted to know, and now I better understand the rationale for the treatment. You guys are good!






    DKA w/ a BS of 303. Hmph. Would be nice to know more about the labs... but who ever remembers that unless it was way out of whack.
  13. by   nursej22
    Does anything seem wrong with this case:
    We received a pt from the ED to our cardiac/tele unit the other night with a dx of new DM and "mild DKA". Pt was lethargic, slurred speech and mainly c/o a headache. Pertinent hx: chronic pancreatitis.
    I don't remember all the labs but here are the biggies:
    Glucose 380
    K+ 3.0
    rest of the metabolic panel showed an anion gap.
    pH acidotic, something like 7.29
    UA: 1000 mg glucose, 4+ ketones.
    In the ED the patient was to be started on NS 200cc/hr until glucose <200, then switch to D/ 1/2 NS at 125hr; regular insulin 5 units IV, and start insulin gtt at 2 units/hr until glucose <200 then dc; hourly glucose checks; metabolic panel q6hr, KCL 40 mEq po once.
    Patient got the 5 units of regular IV, but the ED never started the gtt. In fact the ED nurse got the order dc'd because "they didn't have time to do hourly fingersticks." Pt's glucose came down to 270, they gave 20 units of Lantus subq and then transferred the patient to us, no other insulin orders. On arrival to the floor the glucose was back up to 370.
    The hospitalist was contacted, seemed puzzled that the IV insulin was dc'd. So instead he orders high dose subq protocol which is timed for ac and hs. Well, it's 9pm, so the patient get the 12 units subq per the protocol, and and hour later her glucose is up to 380, but she doesn't have another dose of insulin ordered until breakfast.
    I haven't worked Med/Surg in a while, but ***?
  14. by   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)?

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