1. Give initial IV bolus of 0.2 U/kg actual body weight.
2. Add 100 U of regular insulin to 1 L of normal saline (0.1 U/mL), and follow with continuous IV drip of 0.1 U/kg actual body weight per h until correction of ketosis.
3. Give double rate of infusion if the blood glucose level does not decrease in a 2-h interval (expected decrease is 40-80 mg/dL/h or 10% of the initial value.)
4. Give SQ dose (10-30 U) of regular insulin when ketosis is corrected and the blood glucose level decreases to 300 mg/dL, and continue with SQ insulin injection every 4 h on a sliding scale (ie, 5 U if below 150, 10 U if 150-200, 15 U if 200-250, and 20 U if 250-300 mg/dL).
Shock absent: Normal saline (0.9% NaCl) at 7 mL/kg/h for 4 h, and half this rate thereafter Shock present: Normal saline and plasma expanders (ie,albumin, low molecular weight dextran) at maximal possible rate Start a glucose-containing solution (eg, 5% dextrose in water) when blood glucose level decreases to 250 mg/dL.
Potassium chloride should be added to the third liter of IV infusion and subsequently if urinary output is at least 30-60 mL/h and plasma [K+]
Add K+ to the initial 2 L of IV fluids if initial plasma [K+]
< 4 mEq/L and adequate diuresis is secured.
Half-normal saline (0.45% NaCl) plus 1-2 ampules (44-88 mEq) NaHCC^ per liter when blood pH < 7.0 or total CO2 < 5 mmol/L; in hyper-chloremic acidosis, add NaHCC3 when pH < 7.20; discontinue NaHCC3 in IV infusion when total C02>8-10 mmol/L.
CO2—carbon dioxide; IV—intravenous; K+—potassium ion; NaCl—sodium chloride; NaHCO3—sodium bicarbonate; SQ—subcutaneous.
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