These patients can be very ill and need close observation - preferably in a step-up unit.
There are a few major principles:
1. Stability: patients will need close monitoring of vitals signs, electrolytes, and volume status
2. Volume: initial fluid resuscitation with normal saline. No need to be stingy here with the fluids...patients are litres (usually 6+) low.
3. Glucose: some give an initial small bolus of IV humulin R, others do not. Then IV insulin should be given at about 0.1 U/kg/hr. Follow the anion gap closely - do not stop IV insulin until the anion gap has normalized. If your patients glucose normalizes, you can add dextrose to the IV, but keep them on insulin to prevent ketone production
4. Lytes: Potassium should be watched very closely and replaced. The values may look normal (or even high), but this is from the shift of K into the extracellular compartment secondary to acidosis - there are actually very low total body stores of potassium. Also remember that potassium levels will drop precipitously when insulin is administered as it will shift back into cells. Hmmmm. A good idea is to add 20 meq/L of K to fluids if the serum potassium is between 3.3 - 5 mmol/L, and 40 meq/L if serum potassium is under 3.3 mmol/L. Don't forget about good 'ol sodium too. You may see artificially low levels secondary to the hyperglycemia.
5. Acidosis: Sometimes sodium bicarbonate is given in situations where the pH is low....like less than 7.
6. Precipitants: Ask yourself why this patient went into this state in the first place....See the blog entry from Sept 23, 2008
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