Describe the principle interventions.
Fluid resuscitation: initially with isotonic saline (0.9% NaCl)
Potassium repletion: for potassium level < 5.3 mEq/L
Insulin therapy: initiate short-acting insulin once potassium level is > 3.3 mEq/L
Identify and treat precipitating causes (e.g., sepsis).
Overview (picture).
Describe the fluid resuscitation.
First hour: isotonic saline solution (0.9% sodium chloride) Next 24–48 hours: Adjust IV fluid rate and composition according to CVP, urine output, blood glucose, and corrected sodium levels.
Check corrected sodium for hyperglycemia.
If corrected serum sodium ≥ 135 mmol/L: 0.45% NaCl
If corrected serum sodium < 135 mmol/L: 0.9% NaCl
Switch to a solution containing dextrose (e.g., D5NS) when glucose falls to ∼ 200 mg/dL (DKA) or 300 mg/dL (HHS).
Describe the electrolyte repletion.
Potassium
Potassium levels must be ≥ 3.3 mEq/L before insulin therapy is initiated
If potassium level is < 3.3 mEq/L, potassium should be repleted and rechecked prior to giving any insulin.
If potassium level is < 5.3 mEq/L, the patient will likely require potassium repletion once insulin therapy is started
Maintain serum potassium between 4–5 mEq/L.
It is critical that potassium levels are confirmed to be > 3.3 mEq/L before administering insulin, as insulin will lower serum potassium and potentially cause severe hypokalemia.
Phosphorus: See repletion regimens for hypophosphatemia.
Magnesium: See repletion regimens for hypomagnesemia.
Describe the acid-base status management.
Acidosis usually resolves with fluids and insulin therapy and the use of IV bicarbonate is usually not necessary
If pH < 6.9 despite adequate IV fluid resuscitation, administer IV sodium bicarbonate.
Describe the general principle of insulin therapy.
The administration of insulin is essential in halting lipolysis and ketoacidosis in patients with DKA.
Recommended regimens
IV regular insulin bolus, followed by continuous regular insulin IV infusion
OR regular insulin continuous IV infusion without a bolus
Criteria for resolution of hyperglycemic crises (table).
List DDs.
Other causes of anion gap metabolic acidosis, e.g.:
Alcoholic ketoacidosis
Lactic acidosis
Starvation ketoacidosis
Toxin ingestion
Other causes of hyperglycemia and hypovolemia (e.g., sepsis, acute pancreatitis)
Other causes of AMS, e.g., hypoglycemia
List complications.
Cerebral edema
Cardiac arrhythmias
Heart failure, respiratory failure
Mucormycosis (Mucor and Rhizopus species)
Hypoglycemia
Hypokalemia
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