I work mostly in an Adult Intensive Care Unit now. The other night we had a pt brought to us in severe DKA with Kussmaul breathing, profuse vomiting, altered LOC, and BGL in the 1000s mg/Dl. The intensivist ordered 6 liters LR over a 1-2 hours and insulin. I asked him why LR and he told me that it is like a cheap bi-carb drip that is ready to go for EMS. The lactose gets converted to bi-carb in the liver. He also stated the glucose level is more an annoyance; the real problem is the imbalance. Anyone ever heard of this?
Lacatated Ringers for a DKA pt?
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Rangat
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Heya, the main problem with DKA is the acidotic effect of the glucose & hormone sensitive lipase etc. The body ateempts to correct it partially by secreting Potassium from cells etc. Dehydration is thus also severe, because the glucose increases the tonicity of the blood cuasing a fluid shift from the intracellular space. This is more of a problem with HNKC though.
The preferred fluid is actually 0.9%NaCl, but Ringers is often more practical...
Ringers does contain Lactate, a Bicarbonate precursor. The buffering effect (theoretical) the lactate has in the end is not very well proven as yet, but there hasen't been a better suggestion as yet.
Just remember. Lactate in itself is actually an acid, and if the liver cant metabolise the lactate, you are having an opposite effect.
That is why one doesn't give Ringers to someone with a hypothermic liver(<30`C).
Hope I helped.
Regards
The preferred fluid is actually 0.9%NaCl, but Ringers is often more practical...
Ringers does contain Lactate, a Bicarbonate precursor. The buffering effect (theoretical) the lactate has in the end is not very well proven as yet, but there hasen't been a better suggestion as yet.
Just remember. Lactate in itself is actually an acid, and if the liver cant metabolise the lactate, you are having an opposite effect.
That is why one doesn't give Ringers to someone with a hypothermic liver(<30`C).
Hope I helped.
Regards
Ridryder911
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I agree somewhat, but RL or LR or even Hartman's solution, is sometimes used as was mentioned for the "lactate". One of the primary reasons for use in trauma as well.
I do not understand the reason why not NaHc03 over RL though. Bicarb is much cheaper than a few bags of RL. I do understand hydrating and "flushing" the renal perfusion, but one has to be careful that in DKA the BUN and Amylase level is proficient enough to excrete the excess H+ ions...
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I do not understand the reason why not NaHc03 over RL though. Bicarb is much cheaper than a few bags of RL. I do understand hydrating and "flushing" the renal perfusion, but one has to be careful that in DKA the BUN and Amylase level is proficient enough to excrete the excess H+ ions...
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Rangat
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Well, as I understand, you are right Ridryder. 0.9%NaCl is preferred, because the Acidosis is rather corrected with Bicarb IVI.
After they have tested the K level, short acting Insulin is also given, which will start correcting the dehydrated cells. So only a few Litres of fluid is required in anyway?
After they have tested the K level, short acting Insulin is also given, which will start correcting the dehydrated cells. So only a few Litres of fluid is required in anyway?
Rangat
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Sorry, correction:
K and Na is excreted by the kidneys, causing HYPOkalaemia.
Thats why you don't ever administer the pts Insulin to them, coz their insulin is usually long acting, and will only start working once at hospital.
But most importantly, Insulin causes movement of K into the cells, worsening the hypokalaemia.
K and Na is excreted by the kidneys, causing HYPOkalaemia.
Thats why you don't ever administer the pts Insulin to them, coz their insulin is usually long acting, and will only start working once at hospital.
But most importantly, Insulin causes movement of K into the cells, worsening the hypokalaemia.
Ridryder911
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The only Insuling that is truly fast acting and IV is Regular Insulin. But, since we are not ablle to control hypeglycemia, and as well most of our machines or glucometers are only calibrated for < then 500mg/dl.
It is not unusual to have a patient with hyperkalemia and hypoglycemia, Intravenous calcium may be given to temporarily counteract the muscle and heart effects of hyperkalemia, including some cardiac arrhythmia's.
I.V. D50W and Regular IV insulin moves potassium from the extracellular fluids back into the cells. This may reverse severe symptoms long enough to allow correction of the cause of the hyperkalemia.
Sodium bicarbonate causes potassium to shift from extracellular to intracellular fluids. It may reverse hyperkalemia caused by acidosis with no other treatment required. Prolonged use of sodium bicarbonate should be avoided because it may cause severe complications.
Diuretic medications cause as well decrease body potassium.
Cation-exchange resins, such as sodium polystyrene sulfonate (Kayexalate), are medications that bind (attach to) potassium and cause it to be excreted from the gastrointestinal tract. These medications may be given orally (drinkable or NG tube) or even rectally per enema.
R/r 911
It is not unusual to have a patient with hyperkalemia and hypoglycemia, Intravenous calcium may be given to temporarily counteract the muscle and heart effects of hyperkalemia, including some cardiac arrhythmia's.
I.V. D50W and Regular IV insulin moves potassium from the extracellular fluids back into the cells. This may reverse severe symptoms long enough to allow correction of the cause of the hyperkalemia.
Sodium bicarbonate causes potassium to shift from extracellular to intracellular fluids. It may reverse hyperkalemia caused by acidosis with no other treatment required. Prolonged use of sodium bicarbonate should be avoided because it may cause severe complications.
Diuretic medications cause as well decrease body potassium.
Cation-exchange resins, such as sodium polystyrene sulfonate (Kayexalate), are medications that bind (attach to) potassium and cause it to be excreted from the gastrointestinal tract. These medications may be given orally (drinkable or NG tube) or even rectally per enema.
R/r 911