›Frequent potassium checks
›If potassium > 5.2 mmol/L
›No potassium initially
›Recheck potassium at least every 2 hours early
›IV insulin for DKA or HHS
›Regular insulin infusion 0.1 units per kg per hour
›Alternative without bolus strategy
›Regular insulin infusion 0.14 units per kg per hour
›Local protocol dependent
›Glucose fall target
›2.8 to 4.2 mmol/L per hour
›If not achieved then titration per protocol
›Dextrose addition
›If glucose < 14 mmol/L in DKA
›Add dextrose containing fluids
›Continue insulin to close anion gap
›If glucose < 16.7 mmol/L in HHS
›Add dextrose containing fluids
›Continue gradual osmolality correction
Bicarbonate and phosphate
›Bicarbonate therapy
›If pH < 6.9
›Consider bicarbonate per protocol
›ICU level monitoring
›If pH 6.9 or higher
›No routine bicarbonate
›Treat with fluids and insulin
›Phosphate
›No routine replacement
›Consider replacement if severe hypophosphatemia with weakness
Trigger treatment and infection pathway
›Precipitant management
›Antibiotics when sepsis suspected
›ACS pathway when ischemia suspected
›Stroke pathway when focal deficit present
›Serial monitoring targets
›Glucose every 1 hour on IV insulin
›Electrolytes and anion gap every 2 to 4 hours
›Mental status trending
›Volume status trending
›Transition to subcutaneous insulin
›DKA resolution criteria
›Anion gap closure
›Bicarbonate normalization
›Clinical improvement
›Overlap strategy
›Basal insulin given before stopping infusion
›Overlap 1 to 2 hours