Is it okay to bolus D5 1/2 Normal Saline (D5 1/2NS) for intractable nausea and vomiting with ketones present from starvation ketosis?

Management of Starvation Ketosis with D5 1/2NS for Intractable Nausea and Vomiting

Yes, it is appropriate to bolus D5 1/2NS for intractable nausea and vomiting with ketones present from starvation ketosis, as this provides both hydration and glucose to rapidly reverse the ketotic state. 1, 2

Pathophysiology and Assessment

• Starvation ketosis results from prolonged fasting or inadequate carbohydrate intake, causing the body to metabolize fat for energy, producing ketone bodies 2
• Unlike diabetic ketoacidosis, starvation ketosis presents with normal to low blood glucose levels and typically less severe acidosis (serum bicarbonate usually not below 18 mEq/L) 2
• Intractable nausea and vomiting can both cause and worsen starvation ketosis, creating a vicious cycle that prevents oral intake 3, 4

Treatment Protocol

• Initial Fluid Resuscitation:

  • Begin with D5 1/2NS bolus to simultaneously address dehydration and provide glucose to halt ketogenesis 1, 2
  • For adults with starvation ketosis, a 500-1000 mL bolus of D5 1/2NS is appropriate 2

• Maintenance Therapy:

  • After initial bolus, transition to continuous infusion of D5 1/2NS at a maintenance rate 1
  • The addition of dextrose rapidly corrects the metabolic derangement by providing carbohydrates that inhibit further ketone production 5, 6

Monitoring Parameters

• Monitor blood glucose levels every 1-2 hours initially to prevent both hypoglycemia and hyperglycemia 1
• Check electrolytes (particularly potassium) regularly, as refeeding can cause electrolyte shifts 2
• Assess ketone levels to track resolution of ketosis 2
• Monitor acid-base status if initial presentation included significant acidosis 7

Antiemetic Management

• Concurrent treatment of nausea and vomiting is essential to break the cycle 8
• For persistent nausea and vomiting, consider:
  • Dopamine receptor antagonists (e.g., prochlorperazine, haloperidol, metoclopramide) 8
  • 5HT3 receptor antagonists (e.g., ondansetron) 8
  • Anticholinergic agents and/or antihistamines as adjuncts 8
  • Corticosteroids (e.g., dexamethasone) for refractory cases 8

Transition to Oral Intake

• Once nausea and vomiting are controlled, begin oral carbohydrate intake 2
• Approximately 150-200g of carbohydrate per day (45-50g every 3-4 hours) will prevent recurrence of starvation ketosis 2
• Start with small, frequent meals containing easily digestible carbohydrates 4

Common Pitfalls to Avoid

• Delaying dextrose administration can prolong ketosis and associated symptoms 5
• Failing to distinguish between starvation ketosis and diabetic ketoacidosis may lead to inappropriate insulin administration 2
• Inadequate fluid resuscitation may worsen dehydration and electrolyte abnormalities 7
• Overly aggressive refeeding can lead to refeeding syndrome, particularly in severely malnourished patients 7

Special Considerations

• Pregnant patients are particularly susceptible to starvation ketosis due to increased metabolic demands and may develop more severe acidosis 5
• Lactating women have increased caloric needs and may develop ketosis more rapidly during periods of reduced intake 6
• Children under 7 years of age are prone to "accelerated starvation" with rapid development of ketosis during relatively short periods of reduced caloric intake 4