Diabetic Ketoacidosis (DKA): Management of Electrolyte Imbalances (Nursing)

00:01 Now, after you've been able to restore intravascular volume, right? No matter if it was mild or major, now we've got them to a place of equilibrium.

00:08 Make sure that you look at that sodium.

00:11 If the corrected sodium is normal or elevated, you can even give one-half an isotonic saline at about 250 to 500 mLs an hour.

00:19 Now, I am just giving you examples.

00:22 Please know that most hospitals have a very specific protocol on what they want you to do in the situation.

00:30 For what lab work, how you respond, for sodium, how you respond.

00:33 I'm just giving you an example.

00:35 So please don't critique this based on what you've already seen, I just want you to get an idea.

00:40 If we know the sodium is okay, they may give one-half isotonic saline, 0.45%, at 250 to 500 mLs an hour.

00:48 If the corrected serum sodium is low, you're going to continue with that isotonic saline until the hyponatremia resolves.

00:55 Because we know that we don't want them to have a hypotonic solution if their sodium is already low.

01:01 Now they also look at adding Dextrose, 5 to 10% to the saline solution.

01:06 So keep that in mind depending on what the serum glucose is.

01:10 Again, I'm not giving you a step-by-step plan on what you will exactly do.

01:14 I'm just giving you an idea of the different IV solutions that might be used.

01:19 Now, if the client if the client has a potassium deficit.

01:23 Their potassium is so low, we need to restore that.

01:25 But regardless of what the initial measured potassium was, most patients with DKA have a large total body potassium deficit, okay? So just know this is going to likely be a problem.

01:38 So even if their initial potassium was somewhat okay, if they're in DKA, we expect that they're going to they're probably going to develop a total deficit or a lower level of potassium in their body.

01:49 So you're going to have to manage that and you'll work with the healthcare provider.

01:54 Now how you manage that is we're going to oversee the replacement.

01:57 And how they do that is going to be based on the initial serum level.

02:00 If it was less than 3.5, Now I know I just said, hey, the initial serum level might be okay, but we know they're going to go down.

02:08 That's still true. Both of these things are true.

02:12 Since we anticipate they're going to have a potassium deficit, that's why we look at replacing it before it becomes a major problem.

02:18 Now, less than 3.5, that does indicate a problem if this was their initial potassium.

02:24 So you're going to delay the start of insulin.

02:26 What? Why would you delay starting insulin for a patient in DKA? Well, I'll tell you why.

02:34 Because insulin causes potassium to go into the cell.

02:38 That's going to be a problem if the patient already has a potassium level that's lower than 3.5.

02:44 If you start that insulin right away, you're going to shove more potassium in the cell and push them further and further down into low potassium.

02:52 So, you're going to hold off on the insulin starting that and that's why.

02:57 You're going to give potassium chloride first, 10 to 20 milliequivalents per hour IV until you can get that potassium above 3.5, the bottom of normal.

03:07 Now, rarely additional potassium supplementation might be necessary, but you'll just keep an eye on it and you'll make the decisions with the healthcare provider as you go along.

03:17 Because you don't want too low of potassium, you end up with muscle weakness and cardiac dysrhythmias and that can go really, really bad.

03:24 So, the management of the of the potassium, we know we're going to have to somehow manage it because if they're in DKA.

03:31 If it's lower than 3.5, don't give the insulin right away.

03:34 So if you're taking care of a patient and you know they're in DKA and you're going to start insulin, make sure you know what that potassium level is before you hang that insulin drip.

03:44 Now if it's 3.5 to 5.5, you're going to get potassium chloride 20 to 30 milliequivalents per hour, get IV fluid.

03:50 And you're just going to make sure that that serum potassium stays between four to five.

03:55 Again, that's just a range, make sure you look at the policies at the hospital where you're practicing.

04:00 Now if the potassium is 5.0, do not give potassium.

04:04 Just keep checking that serum potassium level every couple hours and give potassium chloride as needed to keep that serum potassium between our target of four and five.

04:14 Now when you do give the insulin, make sure that patient's potassium is being treated before you give it if the potassium is so low.

04:23 Because if the potassium is less than 3.5, please do not give the insulin.

04:29 Replete the potassium, restore that potassium level and deal with that fluid deficit first, and then you will start the insulin.

04:37 Now bicarbonate and phosphate are rarely indicated.

04:41 Again, so don't come for me.

04:42 I just put this in here that sometimes they might be.

04:44 If the arterial pH is less than seven, you may end up giving some sodium bicarb in sterile water over a couple hours.

04:53 If the serum potassium is less than five, you might add the 20 milliequivalents of potassium chloride.

04:59 Remember, bicarbonate administration may be repeated as needed to raise the pH greater than 7.0, but this is a rare indication.

05:09 I just wanted you to be aware of it.

05:12 So when the serum phosphate is less than one, you're going to add 20 to 30 milliequivalents of potassium phosphate to the IV fluids.

05:19 Now for the monovalent ions, one milliequivalent equals one millimole.

05:23 That's probably what you didn't really come here to know today.

05:27 But again, this is rarely indicated when we're dealing with the bicarbonate and the phosphate, I just wanted you to be aware of it.