• Identify precipitating factors

   ○  ○ Infection, acute coronary syndrome, cerebrovascular accidents, trauma, noncompliance with insulin pharmacotherapy, new-onset diabetes mellitus, and medications (e.g., corticosteroids and sympathomimetics)

• Prepare a comprehensive flow sheet with vitals, laboratory data, fluid type and rates, insulin rates, and other treatments

• Correct fluid abnormalities

   ○  ○ Upon presentation: normal saline infused at 15–20 mL/kg/h (providing 1–1.5 L in the first hour), then 4–14 mL/kg/h for most patients

   ○    ○  ■ Use clinical variables (e.g., blood pressure, heart rate, skin temperature) to target euvolemia; urine output may not be reliable in the hyperglycemic patient

   ○    ○  ■ Monitor for hyperchloremic metabolic acidosis

   ○  ○ If serum sodium rises above 145–150 mEq/L, switch to hypotonic fluid replacement (i.e., 0.45 % saline). Lactated Ringer’s solution may prolong ketoacid production by promoting alkalinization

   ○    ○  ■ Serum sodium may rise with insulin and isotonic saline fluid administration; estimate the corrected serum sodium concentration at presentation:

   ○    ○    ○  □ Add 1.6 mEq/L to the measured serum sodium for every 100 mg/dL rise in blood glucose > 200 mg/dL

   ○  ○ When blood glucose falls to ≤ 200 mg/dL, switch to D5W, D5W/1/2 NS, or D5W/NS depending on plasma sodium concentration

• Regular insulin

   ○  ○ Do not initiate insulin therapy if the serum potassium < 3.5 mEq/L. Maintain potassium levels between 4 and 5 mEq/L during insulin infusion therapy

   ○  ○ Prepare 100 units of regular insulin in 100 mL normal saline (new tubing should be primed with 20 mL of the infusion)

   ○  ○ Use an ideal body weight to dose insulin in obese patients

   ○  ○ Bolus with 0.1 units/kg IV, then 0.05–0.1 units/kg/h continuous IV infusion

   ○    ○  ■ Consider withholding the insulin bolus in the setting of shock until resuscitation is underway; rapid lowering of blood glucose can precipitate worsening of the hypovolemia state

   ○    ○  ■ If blood glucose does not decrease by at least 10 % in the first hour, administer 0.14 units/kg regular insulin bolus then adjust the continuous infusion