Table 11.

Management of acute metabolic complications

Fluid replacement therapy

In the absence of cardiac compromise, isotonic saline (0.9% NaCl) is infused at a rate of 15-20 mL/kg/h or 1-2 l over 1-2 h for prompt recovery of hypotension and/or hypoperfusion

Continue with 0.9% NaCl at a similar rate if patient is hyponatraemic or switch to 0.45% NaCl infused at 250-500 mL/h if the corrected serum sodium is normal (eunatraemia) or elevated (hypernatraemia)

When plasma glucose level is ~200 mg/dL, change to 5% dextrose in saline

Insulin therapy

Start insulin infusion 1-2 h after starting fluid replacement therapy (after initial volume expansion) and serum potassium restored to>3.3 mEq/l

Regular human insulin IV bolus of 0.1-0.15 U/kg followed by continuous insulin infusion at 0.1 U/kg/h

IV bolus is avoided in children as it may increase the risk of cerebral oedema and can exacerbate hypokalaemia

When glucose level reaches 200 mg/dL in DKA or 300 mg/dLin HHS, reduce insulin rate to 0.02-0.05 U/kg/h. Thereafter, adjust rate to maintain glucose level 150-200 mg/dL in DKA and 250-300 mg/dL in HHS

Continue insulin infusion until resolution of ketoacidosis

Subcutaneous rapid-acting insulin analogues (lispro and aspart) every 1-2 h. might be an alternative to IV insulin in patients with mildtomoderate DKA

Initial dose subcutaneous: 0.3 U/Kg, followed 1 h later at 0.1 U/Kg every 1 h, or 0.15-0.2 U/kg every 2 h

Potassium replacement

If patient is hypokalaemic, start potassium replacement at the time of initial volume expansion and before starting insulin therapy. Otherwise, start after initial volume expansion and concurrent with insulin therapy

With initial rapid volume expansion, a concentration of 20 mmol/l should be used

The maximum recommended rate is 0.5 mmol/kg/h

The treatment goal is to maintain serum potassium levels of 4-5 mEq/l

Bicarbonate therapy

Not routinely recommended; only indicated in adults with severe acidosis with pH <6.9

If pH <6.9, consider 100 mmol (2 ampules) in 400 ml sterile water with 20 mEq KCI administered at a rate of 200 ml/h for 2 h.until pH is ≥7.0.

If the pH is still <7.0 after this is infused, we recommend repeating infusion every 2 h. until pH reaches >7.0

Transition to subcutaneous insulin

To prevent recurrence of ketoacidosis or rebound hyperglycaemia, consider overlap of IV insulin for 15-30 min (with rapid-acting insulin) or 1-2 h (with regular insulin) or longer (with intermediate or long-acting insulin) after subcutaneous insulin is given

Most convenient time to change to subcutaneous insulin is just before a mealtime

For patients treated with insulin before admission, restart previous insulin

Regimen and adjust dosage as needed

For patients with newly diagnosed DM, start total daily insulin dose at 0.5-0.8 U/kg/day. Consider multi-dose insulin given as basal and prandial regimen

DKA: Diabetic ketoacidosis, HHS: Hyperosmolar hyperglycaemic state, IV: Intravenous, DM: Diabetes mellitus