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), begin with 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 hydration status, as recommended by the most recent guidelines 1. Start insulin therapy with a continuous IV infusion at 0.1 units/kg/hr. Once blood glucose falls below 200-250 mg/dL, switch to DNS (5% dextrose in normal saline) to prevent hypoglycemia while continuing insulin to clear ketones. Add potassium replacement (20-40 mEq/L) when levels are below 5.3 mEq/L and urine output is adequate. Monitor blood glucose hourly, electrolytes every 2-4 hours, and assess for clinical improvement. The rationale for adding dextrose while continuing insulin is that insulin is needed to suppress ketogenesis even after glucose normalizes. Transition to subcutaneous insulin only when the patient is clinically stable, metabolic acidosis has resolved, and the patient can eat. Overlap IV insulin with subcutaneous insulin by 1-2 hours to prevent rebound hyperglycemia, as supported by recent studies 1.

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

• The use of bicarbonate is generally not recommended, as it has not been shown to improve outcomes 1.
• Phosphate replacement may be necessary in some cases, but its use should be carefully considered 1.
• The management of DKA should be individualized based on the patient's specific needs and clinical status 1.
• The goal of treatment is to restore circulatory volume and tissue perfusion, resolve hyperglycemia and ketoacidosis, and correct electrolyte imbalances 1.

It is essential to follow the most recent guidelines and recommendations for the management of DKA, as they are based on the best available evidence and expert consensus 1.

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 rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus 3.
• Elements of management include making the appropriate diagnosis using current laboratory tools and clinical criteria and coordinating fluid resuscitation, insulin therapy, and electrolyte replacement through feedback obtained from timely patient monitoring and knowledge of resolution criteria 3.
• The three basic principles of treatment for DKA are intravenous fluid therapy, intravenous insulin administration, and potassium replacement 4.

Fluid Resuscitation in DKA

• Normal saline (NS) has been the choice fluid for volume resuscitation in DKA for decades, but large volume resuscitation with NS can lead to hyperchloremic metabolic acidosis and is associated with a higher incidence of major adverse kidney events compared to balanced fluids (BF) 5.
• Balanced crystalloids, such as Sterofundin (SF) or lactated Ringers (LR), may be a superior alternative to NS for fluid therapy in DKA, as they can reduce the risk of complications related to hyperchloremia and improve clinical outcomes 6, 5, 7.
• Studies have shown that patients who received balanced fluids had a shorter time to DKA resolution, required less total intravenous fluid and insulin, and had a lower need for 0.45% saline compared to those who received NS 6, 5.

Special Considerations

• Awareness of special populations, such as patients with renal disease presenting with DKA, is important 3.
• Complications may arise during DKA therapy, and appropriate strategies to prevent these complications are required 3.
• Patient and provider education are important for DKA prevention strategies 3.