Table 1—

Treatment protocol

IV fluids
    1. 0.9% saline at 500–1,000 ml/h for 2 h
    2. 0.45% saline at 250–500 ml/h until blood glucose <13.8 mmol/l (250 mg/dl)
    3. Dextrose 5% in 0.45% saline at 150–250 ml/h until resolution of DKA
Potassium replacement
    1. If serum K+ >5.5 mmol/l, do not give K+, but check serum K+ every 2 h
    2. K+ = 4–5.5 mmol/l, add 20 mmol of KCl to each liter of IV fluid
    3. K+ = 3–4 mmol/l, add 40 mmol of KCl to each liter of IV fluid
    4. K+ = <3 mmol/l, give 10–20 mmol of KCl per hour until serum K+ >3 mmol/l, then add 40 mmol of KCl to each liter of IV fluid
Insulin therapy
    1. SC-1h
        a) Initial dose SC: 0.3 units/kg body wt, followed by
        b) SC aspart insulin at 0.1 units/kg every hour
        c) When blood glucose <13.8 mmol/l (250 mg/dl), change IV fluids to D5% 0.45% saline and reduce SC aspart insulin to 0.05 units · kg−1 · h−1 to keep glucose at ∼11.1 mmol/l until resolution of DKA.
    2. SC-2h
        a) Initial dose SC: 0.3 units/kg body wt, followed by
        b) SC aspart insulin at 0.2 units 1 h later and every 2 h
        c) When blood glucose <13.8 mmol/l (250 mg/dl), change IV fluids to D5% 0.45% saline and reduce SC aspart to 0.1 units/kg every 2 h to keep glucose at ∼11.1 mmol/l (200 mg/dl) until resolution of DKA
    3. IV regular insulin
        a) Initial IV bolus: 0.1 units/kg body wt, followed by
        b) Continuous insulin infusion at 0.1 units · kg−1 · h−1
        c) When blood glucose <13.8 mmol/l (250 mg/dl), change IV fluids to D5% 0.45% saline and reduce insulin infusion rate to 0.05 units · kg−1 · h−1 to keep glucose at ∼11.1 mmol/l until resolution of DKA
    4. Laboratory
        a) Admission: Cell blood count with differential complete metabolic profile, venous pH, and serum β-hydroxybutyrate
        b) During treatment: Basic metabolic profile (glucose, bicarbonate, sodium, potassium, chloride, urea, and creatinine), venous pH, phosphorus, and β-hydroxybutyrate at 2 h, 4 h, and every 4 h until resolution of DKA
        c) Glucose by fingerstick: Check glucose every hour in patients receiving SC-1 h and every 2 h in patients receiving IV insulin or SC-2h