Initial Treatment Insulin and Potassium

Management of DKA involves administration of insulin, water, and electrolytes safely to prevent marked fluid shifts into the brain and a precipitous drop in potassium, which would impair compensatory hyperventilation. Insulinization promptly blocks further liposis and shuts down ketogenesis. R insulin is given as an intravenous (IV) bolus of 0.1 U/kg with the start of saline administration. Some suggest the initial bolus should be as much as 20 U. The bolus infusion is followed by a continuous infusion of 0.1 U/kg/hr, with hourly adjustments based on decline in serum glucose and reversal of acidosis. Low-dose insulin infusions are safe if the potassium value is monitored, and improving metabolic parameters should be apparent in 1 or 2 hours. Some patients may be remarkably resistant, and a significant bolus adjustment of up to 20 units may be necessary in 1 hour, with modification of the infusion concentration. The objective is not to decrease glucose precipitously but to turn off ketosis. Rapid glucose reductions with more aggressive insulinization protocols have resulted in fluid shifts, especially in children, which may account for the most serious complication, cerebral edema.

The serum potassium value on presentation can be estimated by reviewing the ECG. Peaking of the T wave with P-wave flattening or worse, QRS widening, means that the full protocol should be instituted at once with continued ECG monitoring to prevent a hyperkalemic cardiac crisis. If there is no evidence of hyperkalemia, and certainly if there is flattening of the T wave with a U wave, indicating the opposite risk of hypokalemia, then potassium chloride or phosphate should be given as long as urine flow is apparent. This situation requires caution with fluid and insulin administration to avert a drop in potassium caused by a rapid intracellular glucose shift. Cardiac monitoring should be continued and renal function ascertained immediately by BMP or urine flow to assess the amount and speed of potassium replacement.

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