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Management of Severe Hyperglycemia / DKA

- See: 
- Stable HyperGly 
- Sliding Scale 
- Management of Stable DKA Patient
- Management: 
   - correct volume depletion; 
   - give 500 ml NS IV "wide open." then continue as needed; 
   - caution with CHF; 
   - begin insulin; - give 5-10 units of IV regular insulin as single dose by direct slow injection followed by an infusion rate based on chemstrip or glucometer readings, initially q1hr; 
   - don't use SC Insulin; may have poor circulation; 
   - d/c all SC insulin dosing and oral hypoglycemics; 
   - regular insulin can bind to plastic IV tubing; 
   - hence, 30-50 ml of infusion solution should be run thru IV tubing and discarded, before the IV tubing is attached to patient; 
   - ideal rate of blood glucose lowering is 75-100 mg/dL/hr; 
   - more rapid drop may lead to osmotically induced fluid shifts, manifested by confusion / CNS symptoms; 
   - start insulin infusion at 0.1 Units/kg/hr until plasma glucose reaches 250, then d/c insulin infusion and begin IV D5W; 
   - expect plasma glucose to fall about 10% over 2 hr; 
   - if glucose levels do not fall, then pt has insulin resistance and infusion rate must be increased to 0.15-0.2 Units/kg/hr; 
   - monitor Blood Glucose, Lites, ABGs for initial baseline & after 2hrs; 
   - watch for: 
       - hypophosphatemia: 
       - metabolic acidosis: bicarbonate if pH < 7.1; - hypolkalemia
       - after IV NS & insulin are given & acidosis corrected, potassium deficit may become esp severe; 
       - when hypokalemia is first noted, add KCl to infusion, provided that pt is passing urine & Urea & Cr are normal; 
       - w/ concomitant RF pt may suffer iatrogenic Hyper Cl
       - in pts w/ severe electrolyte and mineral derangements, such as DKA and ETOH, some authors recommend administration of phosphorus, magnesium, and potassium in the same intravenous solution; 
       - 20 millimoles K Phos, 20 millimoles K Cl, & 4 ml of 50% Mg SO4 in 0.45% saline given q 8 hrs; 
       - A clinical approach to common electrolyte problems: 3. Hypophosphatemia. 

The metabolic derangements and treatment of diabetic ketoacidosis.