How to manage Diabetic Ketoacidosis (DKA) with Dehydration (DNS likely referring to Dehydration Not Specified or possibly Diabetes Nurse Specialist, but in this context, it seems to refer to a state of dehydration)?

From the Guidelines

To manage diabetic ketoacidosis (DKA) with DNS (Dextrose Normal Saline), start with aggressive fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour, then reduce to 250-500 mL/hr based on hemodynamic status, as recommended by the most recent guidelines 1. Begin insulin therapy with a continuous IV infusion at 0.1 units/kg/hr. Once blood glucose falls below 250 mg/dL, switch to DNS (5% dextrose in 0.9% normal saline) to prevent hypoglycemia while continuing insulin to clear ketones. Add potassium replacement when levels are below 5.2 mEq/L and urine output is adequate. Monitor electrolytes, glucose, and pH every 2-4 hours. Continue this regimen until anion gap normalizes, pH exceeds 7.3, and bicarbonate is above 18 mEq/L. This approach works because insulin suppresses ketogenesis and promotes glucose utilization while the dextrose prevents hypoglycemia, allowing continued insulin administration to clear ketones even after glucose normalizes. Fluid replacement corrects dehydration and improves renal perfusion, helping to clear glucose and ketones.

Some key points to consider in the management of DKA include:

• The use of bicarbonate is generally not recommended, as several studies have shown that it makes no difference in the resolution of acidosis or time to discharge 1.
• Phosphate replacement may be indicated in patients with cardiac dysfunction, anemia, or respiratory depression, and in those with serum phosphate concentration < 1.0 mg/dl 1.
• The transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
• Patients with uncomplicated DKA may sometimes be treated with subcutaneous insulin in the emergency department or step-down units, an approach that may be safer and more cost-effective than treatment with intravenous insulin 1.

The most recent and highest quality study, published in 2025 1, provides the best guidance for the management of DKA, and its recommendations should be followed to optimize patient outcomes.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

To manage Diabetic Ketoacidosis (DKA) with DNS (Diabetic Nurse Specialist), the key steps are:

• Monitor blood glucose and ketone levels closely
• Administer insulin as prescribed by the doctor
• Provide hydration to prevent dehydration
• Monitor for signs of severe DKA, such as heavy breathing, rapid pulse, and loss of consciousness
• Seek medical assistance immediately if symptoms worsen or if the patient experiences severe DKA symptoms 2

From the Research

Management of Diabetic Ketoacidosis (DKA)

• DKA is a hyperglycemic emergency that requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event 3.
• The most common precipitating causes for DKA include infections, new diagnosis of diabetes, and nonadherence to insulin therapy 3.

Fluid Management in DKA

• Normal saline (NS) has been the traditional choice for fluid resuscitation in DKA, but recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 4, 5.
• Balanced fluids (BF) may be associated with a shorter time to DKA resolution compared to NS 4.
• Large-volume resuscitation with isotonic NS is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis 5.
• Balanced crystalloid solutions, such as lactated Ringers, may result in better outcomes for patients with DKA, including faster resolution of acidosis, less hyperchloremia, and shorter hospital length of stay 6.

Key Considerations in DKA Management

• Proper management of DKA requires frequent monitoring of patient's clinical and laboratory states 3.
• Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA 3.
• Patient education programs focusing on adherence to insulin and self-care guidelines during illness can help reduce future episodes of DKA 3.