What is the appropriate increase in D5 (Dextrose 5%) infusion rate for a patient with ketonuria (ketones 1.98) and not eating, currently receiving D5 at 100ml/hr?

Management of Persistent Ketonemia in NPO Patient on D5 Infusion

Increase the D5 infusion rate to 150-200 mL/hr and add insulin coverage to clear the ketones, as dextrose alone will not resolve ketonemia—the patient requires both glucose substrate and insulin to suppress ketogenesis and clear ketones. 1, 2

Understanding the Clinical Problem

Your patient has significant ketonemia (1.98 mmol/L) despite receiving D5 at 100 mL/hr, indicating ongoing ketogenesis from starvation. The current dextrose delivery is insufficient to suppress ketone production. Ketonemia typically takes longer to clear than hyperglycemia, and requires adequate glucose delivery plus insulin to resolve. 1, 2

• The patient is receiving only 5 grams of dextrose per 100 mL, meaning 100 mL/hr delivers just 5 grams/hour or 120 grams per 24 hours 1
• Adults require 150-200 grams of carbohydrate daily to prevent or reduce starvation ketosis 1
• Current delivery falls short of this minimum threshold by 30-80 grams daily 1

Recommended Dextrose Adjustment Algorithm

Increase D5 to 150-200 mL/hr to deliver 180-240 grams of dextrose per 24 hours, meeting the minimum carbohydrate requirement to suppress ketogenesis. 1

Specific Rate Calculation:

• Target: 150-200 grams carbohydrate per 24 hours 1
• D5 provides 5 grams per 100 mL
• Minimum rate: 125 mL/hr (150 grams/24 hours) 1
• Optimal rate: 150-200 mL/hr (180-240 grams/24 hours) 1

Critical Addition: Insulin Coverage Required

Dextrose infusion alone is insufficient—you must add insulin coverage to actively clear ketones. 1, 2

• Continue intravenous insulin infusion at 0.05-0.1 units/kg/hr even with normal glucose levels 1
• Target glucose between 150-200 mg/dL until ketones clear (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) 1, 2
• If patient is NPO and DKA/ketosis is resolved but ketones persist, give subcutaneous regular insulin every 4 hours: 5 units for glucose 150-200 mg/dL, 10 units for 200-250 mg/dL, 15 units for 250-300 mg/dL, 20 units for >300 mg/dL 2

Monitoring Protocol

Check blood glucose, electrolytes (especially potassium), venous pH, and beta-hydroxybutyrate every 2-4 hours until ketones normalize. 1, 2

• Direct measurement of beta-hydroxybutyrate is preferred over urine ketones 2, 3
• Venous pH adequately tracks acidosis resolution without repeated arterial sticks 2, 3
• Ensure potassium is maintained between 4-5 mEq/L, as insulin administration drives potassium intracellularly 1, 3

Common Pitfalls to Avoid

Do not increase dextrose without insulin coverage—this will raise glucose but fail to clear ketones, as insulin is required to suppress lipolysis and ketogenesis. 1, 2

Do not rely on urine ketones to monitor treatment response—the nitroprusside method only measures acetoacetate and acetone, missing beta-hydroxybutyrate (the predominant ketoacid), and can paradoxically worsen during treatment as beta-hydroxybutyrate converts to acetoacetate. 1, 2, 3

Do not stop insulin infusion when glucose normalizes—ketonemia takes longer to clear than hyperglycemia, requiring continued insulin therapy with dextrose supplementation. 1, 2

Transition Planning

Once the patient can eat, transition to a multiple-dose subcutaneous insulin regimen combining short/rapid-acting and intermediate/long-acting insulin. 2, 4

• Continue IV insulin for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 2
• Basal insulin coverage is critical, particularly in type 1 diabetes patients, even when not eating 2

Special Consideration: Euglycemic DKA

If this patient has diabetes and ketones 1.98 mmol/L with relatively normal glucose, consider euglycemic DKA, particularly if on SGLT2 inhibitors. 5, 6

• In euglycemic DKA, start D5 alongside 0.9% NaCl at the beginning of insulin treatment 1
• Persistent glucosuria and ketonuria with glucose below renal threshold confirms ongoing ketogenesis 6