DKA Priorities

[hiddencatRN, BSN, RN]

Last quarter, two of our professors taught us that for patients in DKA, the priorities are fluid first, then IV insulin, then address electrolyte imbalances. This quarter, we're being taught insulin first, then fluids, then electrolytes. It seems to me that the reality is that the hydration and insulin is probably happening at the same time, but as a testing point, which is the priority?

[RNTutor, BSN, RN]

You're right...both would be done so quickly, they might as well be done at the same time! But in my Med-Surg book, fluid replacement is listed first.

Honestly, I don't believe an NCLEX question would ask you to differentiate between the importance of those 2 essential things. But a classroom exam is different, in that case I would probably go with what the instructor has taught.

And always go with the context of the question, which can definitely change your perspective. For example, when I was in nursing school, we had a question asking what is the first thing we would do to help a burn pt on the scene of the fire. Several people automatically went straight to their ABCs, and selected "Administer O2." Normally a great choice, but their critical thinking skills had left them that day since one of the other possible choices was "Put out the fire on the pt's clothing." The context of the question/answer can change everything.

[hiddencatRN, BSN, RN]

Thanks!

[RNTutor, BSN, RN]

I was talking to very experienced nursing professor today, and this topic came up. I like her answer waaay better than mine, so I wanted to share it with you.

She said that in DKA, you give insulin first because that is the underlying problem...a complete lack of insulin. And no amount of water is going to help that pt unless they also get insulin.

But for HHNK, you give water first, then insulin. You do it in this order for HHNK because their blood glucose tends to be extremely high, sometimes in the thousands, which has led to dehydration (due to polyuria r/t the high blood glucose). So since they are so dehydrated, but their body is making some insulin, then we would try to rehydrate first before giving exogenous insulin.

See, it's true that you never do stop learning as a nurse!

[talaxandra]

As an endocrine CNS I have to disagree - waiting half an hour or so to start up the insulin infusion won't have nearly the same risks as waiting to start fluids. Some DKA patients are significantly hypovolemic, not only hypotensive and tachycardic but straining organs (particularly the kidneys) that are already at risk of long term damage from the diabetes.

[talaxandra]

i thought you might like some support for my position, so i googled dka and priority and got a really useful australian icu dka protocol. that was the second google hit - and from every other relevant hit from the first two pages:

[color=#767676]"the initial priority in the treatment of diabetic ketoacidosis is the restoration of extracellular fluid volume through the intravenous administration..." (source);

"although the first priority in treatment is to restore fluid balance to the patient, the other causes of dka must also be addressed before a full recovery..." (source);

"during the management of dka first priority is to replenish fluids.6 ,7 the initial fluid should be an isotonic solution like normal saline... (source);

"the restoration of an adequate intravascular volume is the first priority in the treatment of dka..." (source); and

"the priority in managing dka is to rectify the fluid and electrolyte losses (see ch. 8) and to treat the insulin deficiency."(source)

[RNTutor, BSN, RN]

Interesting...and same rationale for HHNK? Fluids first then insulin?

[talaxandra]

Yes, although they're usually less sick.

For what it's worth, the highest blood glucose I've come across was in a T1DM in DKA (120.8mmol/L or 2,174.4mg/dL) who drank flavoured milk and juice to unsuccessfully quench her increasing thirst.

[RN2800]

Hello,

I have read online recently on EMCRIT that fluids are certainly first, and that the urgent need for rehydration and electrolyte replacement depends on the severity of dehydration. A patient with DKA who delays treatment, has a secondary infection present, or high lactate levels and thus profound metabolic acidosis will certainly need fluid resuscitation first. Giving insulin prior to restoring ECF balance can be risky, as it will drive down potassium. Not so important if your Pts K levels are already elevated, but the drop in K levels can be profound and dangerous when you then reydrate with only NS plus giving insulin boluses at the same time. Not to mention for most DKA patients, if the ketones are high enough, they will have an anion gap acidosis. Better to give Plasmalyte or a balanced solution that does not contain too much chloride. In the MedSurg and ICU floors we don't have plasmalyte so I'm wondering what the next best choice would be to rehydrate the ECF.

Some DKA protocols call for as much as 3 L rehydration within the first hour, then you can give a bolus of insulin so the Pt will stop producing lactate.

And as always it seems that the condition the kidneys are in would be a factor, or if the Pt has been down for awhile and has very elevated CK levels. Can anyone out there comment on (the best) fluid resuscitation in a DKA Pt that is also in ARF?