DKA and fluid resuscitation

[GingerSue]

In my textbook, about DKA and its treatment:

"because fluid imbalance is potentially life threatening, the initial goal of therapy is to establish intravenous access and begin fluid and electrolyte replacement. Typically the initial fluid therapy regimen comprises an infusion of dextrose 3.3 percent and sodium chloride 0.3 percent (2/3 and 1/3) IV solution premixed with a specified amount of potassium (KCL) at a rate to restore urine output to 30 to 60 mL/hr and to raise blood pressure. When blood glucose levels approach 14 mmol/L, 5 percent dextrose is added to the fluid regiment or prevent hypoglycemia"

but on the next page - about Emergency Mangement of DKA:

"begin fluid resuscitation with 0.9 % NaCl solution until BP stabilized and urine output 30 to 60 mL/hr"

Is NaCl or 2/3 and 1/3 used to start fluid resuscitation?

[deeDawntee, RN]

Hi!

Boy confusing, huh?

I just took and passed the CCRN exam and for their purposes the fluid of choice is NS (along with insulin gtt) until BG reaches about 250 and then to start fluids with dextrose. I imagine different institutions have different protocols though and of course would recommend following your institutions protocol. One does not want to drop these pt's glucose levels too low or too fast, and perhaps that is why the first fluid is recommended. Either way, what is important is to not let the pt's blood glucose get too low, because a paradoxical cerebral edema can result.

Another issue may be that I don't know of anywhere I have worked who stocks that Dextrose 33% and 0.3% saline. That sounds like something that pharmacy would have to mix up specially and there isn't always the time or a pharmacist available in all institutions.

[GingerSue]

"...infusion of dextrose 3.3 percent and sodium chloride 0.3 percent (2/3 and 1/3) IV solution

but on the next page - about Emergency Mangement of DKA:

fluid resuscitation with 0.9 % NaCl solution

thanks,

but it's 3.3% not 33% (so this would be the usual 2/3 - 1/3)

[cardiacRN2006, ADN, RN]

We always seem to use LR for DKA resusciatation, and we never add the K until I know it's under control, since it's normally sky high!

We also watch as the BS returns to 250, and then begin to add the D5...

[classicdame, MSN, EdD]

Remember, water follows sugar (and salt). If all the sugar is in the blood, not the cells, then the patient is dehydrated. This can lead to organ failure. So the first step is to correct dehydration. Later you add K or Dextrose, but NS comes first.

[talaxandra]

We always start with N/saline, run K+ according to serum potassium (from 20mmol/hr if the K+ is less than 3.5mmol/L to 5 mmol/hr if it's over 5), and add 5% dextrose when the BSL hits 15mmol/L (270mg/dL).

The N/S is to counter dehydration, the K= replacement because IV insulin causes potassium to shift out of the blood stream, and the dextrose slows the drop in serum glucose because sudden shifts in serum glucose increase the risk of long-term diabetic complications.

[Nrs_angie, BSN, RN]

Hi!

Boy confusing, huh?

I just took and passed the CCRN exam and for their purposes the fluid of choice is NS (along with insulin gtt) until BG reaches about 250 and then to start fluids with dextrose. I imagine different institutions have different protocols though and of course would recommend following your institutions protocol. One does not want to drop these pt's glucose levels too low or too fast, and perhaps that is why the first fluid is recommended. Either way, what is important is to not let the pt's blood glucose get too low, because a paradoxical cerebral edema can result.

Another issue may be that I don't know of anywhere I have worked who stocks that Dextrose 33% and 0.3% saline. That sounds like something that pharmacy would have to mix up specially and there isn't always the time or a pharmacist available in all institutions.

Dawn hit the nail on the head....

couldn't have said better myself

[classicdame, MSN, EdD]

Initial treatment will probably be NS. I know for sure that is the only IV fluid on the EMS ambulances in our county.

DKA causes dehydration. NS is generally used initially, then other fluids may be added depending on lab values. I think your textbook is confusing, but when tested I would go with NS.

[ckc6977]

I concur with the other previous posts. At our facility we begin the pt on NS (usually c K+ supplements added also of course c the insulin gtt). Once the BG levels are = 250, we'll switch the IVF to D5NS, D51/2NS.