Management of Adult Patients with DKA Complete Initial Evaluation1, Start IV luida !

1"# $ of #"%& 'aCl per hour initiall( )1*+,# ml"Kg+1"h+1-"

IV Fluida Insulin Potassium Assess need for Bicarbonate

,etermine )*dration status

IV 8oute

&C I( 8oute

)*#o+olemic &!oc'

(ild )*#otention

Cardio%enic &!oc'

Insulin 7 8e%ular 0.11 units '% as IV bolus

Insulin 7 8e%ular 0.0 units '% 1 5 IV bolus9 1 5 I( or &C

If initial serum 3. is B ?.? m-6 L9 !old insulin and %i+e 00 m-6 3. #er C! (5 ? 3CL and 1 ? 3P="9 until 3 D ?.? m-6 L

#) B @.9

#) @.9 > :.0

#) E :.0

Administer 0.9% NaCl (1.0 L !" and or #lasma e$#ander

)emo monitorin%

d*namic

0.1 units 3%21.!21 IV insulin infusion

0.1 units 3%21.!21 8e%ular insulin &C or I(

If initial serum 3. is E 1.0 m-6 L9 donFt %i+e 3. but c!ec' 3. e+er* 5!

Na)C=? (100 mmol" ,ilute in 000 ml )5= Infuse at 500 ml !

Na)C=? (10 mmol" ,ilute in 500 ml )5= Infuse at 500 ml !

No )C=?

-+aluate Corrected serum Na.1

If serum %lucose does not fail b* 102:0 m% dl in first !our

If initial serum 3. is D ?.? but B 1.0 m-6 L9 %i+e 502 ?0 m-6 3. in eac! liter of IV fluid (5 ? 3CL and 1 ? 3P="9 to 'ee# serum 3. at 021 m-6 L

8e#eat )C=? adminidtration e+er* 5 ! until #) E :.0. (onitor serum 3.

&erum Na !i%!

&erum Na Normal

&erum Na Lo/

,ouble insulin infusion !ourl* until %lucose falls b* 102:0 m% dl

;i+e !ourl* IV insulin infusion bolus (10 units" until %lucose falls b* 102:0 m% dl

0.01% NaCl (0210 ml.3%21.!21" de#endin% on !*dratition state

0.9% NaCl (0210 ml.3%21.!21" de#endin% on !*dratition state

4!en &erum %lucose reac!es 510 m% dl

C!an%e to 1% de$trose /it! 0.01% NaCl at 1102510 ml ! /it! ade6uate insulin (0.0120.1 units 3%21.!21 IV infusion or 1210 units &C e+er* 5!" to 'ee# t!e serum %lucose bet/een 110 and 500 m% dl until metabolic control is ac!ie+ed.

C!ec' electrol*tes9 B<N9 creatinine and %lucose e+er* 520!9 until stable. After resolution of ,3A9 if t!e #atient is NP=9 continue IV insulin and su##lement /it! &C re%ular insulin as needed. 4!en t!e #atient can eat9 multi#le dos sc!edule s!ould be started t!at uses combination of s!ort or ra#id actin% and intermediate or lon% actin% insulin as needed to control #lasma %lu'ose. Initiate &C insulin 0.1 > 1.0 u.3% 21. d21 %i+en as 5 ? a.m9 1 ? in #m or as 0.1 > 0.51 unit.'% re%ular e+er* @2 A !ours durin% t!e first 50 !ours for ne/ #atients to determine re6uirement. Continue IV insulin influssion for 1+, h after SC insulin as .egun to ensure ade/uate plasma insulin level" Continue to loo0 for pre1ipitating 1auses )s-

Management of adult Patient with 22s Com#lete Initial e+aluation9 &tart IV fluids 7 1.0 L of 0.9% NaCl #er !our Initiall*
IV Fluida Insulin Potassium

,etermine )*dration status

)*#o+olemic &!oc'

(ild )*#otention

Cardio%enic &!oc'

Insulin 7 8e%ular 0.11 units '% as IV bolus

If initial serum 3. is B ?.? m-6 L9 !old insulin and %i+e 00 m-6 3. #er C! (5 ? 3CL and 1 ? 3P="9 until 3 D ?.? m-6 L

Administer 0.9% NaCl (1.0 L !" and or #lasma e$#ander

)emo monitorin%

d*namic

0.1 units 3%21.!21 IV insulin infusion

If initial serum 3. is E 1.0 m-6 L9 donFt %i+e 3. but c!ec' 3. e+er* 5!

-+aluate Corrected serum Na.1

C!ec' serum %lucose !ourl*9 If serum %lucose does not fail b* 102:0 m% dl in first !our

If initial serum 3. is D ?.? but B 1.0 m-6 L9 %i+e 502 ?0 m-6 3. in eac! liter of IV fluid (5 ? 3CL and 1 ? 3P="9 to 'ee# serum 3. at 021 m-6 L

&erum Na !i%!

&erum Na Normal

&erum Na Lo/

,ouble insulin infusion !ourl* until %lucose falls b* 102:0 m% dl

0.01% NaCl (0210 ml.3%21.!21" de#endin% on !*dratition state

0.9% NaCl (0210 ml.3%21.!21" de#endin% on !*dratition state

4!en &erum %lucose reac!es ?00 m% dl

C!an%e to 1% de$trose /it! 0.01% NaCl and decreased insulin to0.0120.1 units 3%21.!21 IV infusion to 'ee# t!e serum %lucose bet/een 510 and ?00 m% dl until #lasma osmolalit* is G ?11 m=sm '% and #atient mentall* alert.

C!ec' electrol*tes9 B<N9 creatinine and %lucose e+er* 520!9 until stable. After resolution of ,3A9 if t!e #atient is NP=9 continue IV insulin and su##lement /it! &C re%ular insulin as needed. 4!en t!e #atient can eat9 multi#le dos sc!edule s!ould be started t!at uses combination of s!ort or ra#id actin% and intermediate or lon% actin% insulin as needed to control #lasma %lu'ose. Initiate &C insulin 0.1 > 1.0 u.3% 21. d21 %i+en as 5 ? a.m9 1 ? in #m or as 0.1 > 0.51 unit.'% re%ular e+er* @2 A !ours durin% t!e first 50 !ours for ne/ #atients to determine re6uirement. Continue IV insulin influssion for 125 ! after &C insulin as be%un to ensure ade6uate #lasma insulin le+el. Continue to loo' for #reci#itatin% causes (s"