›Insulin before fluids worsens hypotension
›No insulin until K+ >= 3.3 mmol/l
›Potassium confirmed adequate
›Life-threatening hypokalemia if insulin given with K+ < 3.3 mmol/l
›Replace potassium before insulin in this scenario
›ADA insulin protocol
›Option 1 with bolus
›IV bolus 0.1 units/kg
›Then continuous infusion 0.1 units/kg/h
›Option 2 without bolus
›Continuous infusion 0.14 units/kg/h
›No initial bolus
›JBDS lower-dose protocol
›Initial rate 0.05 units/kg/h
›Titrate up by 1 unit/h as needed
›May be appropriate for elderly or sensitive patients
›Glucose targets during infusion
›Target glucose decline 2.8 to 4.2 mmol/l per hour
›If not achieved, double infusion rate
›If declining faster, reduce infusion rate
›When glucose < 16.7 mmol/l
›Reduce to 0.02 to 0.05 units/kg/h
›Add D5 to IV fluids concurrently
›Subcutaneous insulin transition
›Basal insulin given 2 to 4 hours before stopping IV insulin
›Prevents rebound hyperglycemia
›Class I recommendation critical pitfall avoidance
›Continue IV insulin until osmolality normalizing and patient eating
›Potassium management protocol
›K+ < 3.3 mmol/l
›Hold insulin completely
›Give 20 to 40 mmol/h IV KCl until K+ > 3.3 mmol/l
›K+ 3.3 to 5.2 mmol/l
›Add 20 to 40 mmol K+ per liter of IV fluids
›Check levels every 2 hours during active treatment
›K+ > 5.2 mmol/l
›Hold potassium supplementation
›Recheck in 2 hours
›Monitor for ECG changes
›Anticoagulation strategy
›LMWH prophylaxis recommended
›High thrombotic risk far greater than DKA
›Prophylactic heparin associated with reduced mortality (OR 0.033 in one study)
›Enoxaparin dosing
›40 mg SC daily for standard prophylaxis
›Dose adjust for renal impairment
›Therapeutic anticoagulation if confirmed thrombosis
›DVT or PE management per standard protocol
›Arterial thrombosis requires vascular surgery consultation
›Infection management
›Broad spectrum antibiotics if sepsis suspected
›Initiate within 1 hour of septic shock recognition
›Narrow based on culture results
›Antibiotic selection by source
›Pneumonia community acquired: ceftriaxone 2 g IV daily plus azithromycin 500 mg IV daily
›UTI: ceftriaxone 1 g IV daily or ciprofloxacin 400 mg IV every 12 hours
›ACS management
›Cardiology consultation immediately
›Dual antiplatelet if STEMI or NSTEMI confirmed
›Anticoagulation per ACS protocol
›Manage hyperglycemia carefully
›Tight glucose targets during ACS may worsen outcomes
›ADA target glucose 7.8 to 10 mmol/l during ACS
›Medication precipitants
›Discontinue offending agent when possible
›Glucocorticoid dose reduction if clinically feasible
›Antipsychotic switch with psychiatric consultation
›Diuretic reassessment
›Hold thiazides and loop diuretics initially
›Restart with endocrinology guidance
›Rhabdomyolysis
›IV fluid target urine output > 1 mL/kg/h
›Aggressive hydration to prevent myoglobin nephropathy
›Monitor urine color and CK trend
›Nephrology if creatinine rising despite hydration
›Dialysis may be required for severe AKI
›Hemodialysis shown to improve renal prognosis in case reports
›Cerebral edema
›Higher risk in pediatric patients
›Slower osmolality correction in children
›Target osmolality decline < 3 mOsm/kg/h
›If suspected
›Mannitol 0.5 to 1 g/kg IV or hypertonic saline 3%
›Neurology and neurosurgery consultation