›Correction dose from the patient's sensitivity factor, or about 0.1 unit/kg if unknown
›Target glucose about 8-10 mmol/l
›Do not repeat within 3 hours because of stacking and later hypoglycaemia
›Use the abdomen or thigh, away from any lipohypertrophy
›Oral fluids
›Encourage water or a sugar-free electrolyte drink if the patient is tolerating oral intake
›Recheck at 2-3 hours
›Glucose and blood beta-hydroxybutyrate
›Escalate to the ketoacidosis pathway if ketones or the anion gap rise
›Give the long-acting bridge dose before discharge if the pump is not back in service
Intravenous fluid resuscitation
›First-hour resuscitation
›0.9% sodium chloride or a balanced crystalloid 15-20 ml/kg (about 1-1.5 l in an adult) over the first hour
›Give a smaller 250-500 ml aliquot with reassessment if there is heart failure, chronic kidney disease, or age over 70
›Balanced crystalloid may shorten time to resolution and cause less hyperchloraemic acidosis
›Ongoing replacement
›After the first hour, 250-500 ml/hr guided by the corrected sodium
›Corrected sodium normal or high: 0.45% sodium chloride
›Corrected sodium low: continue 0.9% sodium chloride
›Add dextrose when glucose falls to 14 mmol/l
›Change to 5% dextrose with 0.45% sodium chloride at 150-250 ml/hr and continue insulin
›Use 10% dextrose if glucose keeps falling while the anion gap is still open
›Estimated deficit
›About 100 ml/kg (commonly 6-8 l in an adult); replace over 24-48 hours, not as a single bolus load
›Threshold exceptions
›Cardiac or renal failure, dialysis dependence, and older age call for smaller aliquots and serial lung ultrasound
›Children use weight-based boluses with strict ceilings (see Pediatrics)
›Monitoring during fluids
›Hourly urine output, serial lung examination or ultrasound, corrected sodium every 2-4 hours
Intravenous insulin infusion for diabetic ketoacidosis
›Preconditions
›Potassium known and 3.3 mmol/l or above; if below, replace potassium first and delay insulin
›Fluids already running
›Regular (soluble) insulin infusion
›0.1 unit/kg/hr intravenous infusion
›Optional initial 0.1 unit/kg intravenous bolus; omit the bolus and run 0.14 unit/kg/hr if a bolus is undesirable
›Aim for a glucose fall of 2.8-3.9 mmol/l per hour
›If the first-hour fall is under 2.8 mmol/l and the line is confirmed patent, give 0.14 unit/kg intravenously and double the rate
›When glucose falls to 14 mmol/l, reduce to 0.02-0.05 unit/kg/hr and add intravenous dextrose
›Keep glucose between 8 and 11 mmol/l until the anion gap closes and blood beta-hydroxybutyrate is below 0.6 mmol/l
›Threshold exceptions
›In children, aim for a fall no faster than 5 mmol/l per hour and start dextrose earlier (see Pediatrics)
›Targets are tighter in pregnancy (maternal glucose 5-8 mmol/l) and approached more cautiously in older adults and chronic kidney disease
›Do not stop insulin when the glucose normalises
›Ketogenesis continues; maintain insulin with dextrose cover until the gap closes
›Transition to subcutaneous insulin
›Give a long-acting analog dose and overlap the infusion by 1-2 hours before stopping it
›Therapy-not-working troubleshooting
›Glucose not falling despite an adequate rate: confirm the pump is disconnected, the line is patent, and the bag concentration is right; then look for sepsis, myocardial infarction, missed steroids, or pregnancy
›Anion gap not narrowing with a normal glucose: dextrose was not started or the rate was cut too early; restart dextrose and hold insulin at 0.05 unit/kg/hr
›Persistent acidosis with a closed ketone gap: expected hyperchloraemic acidosis, or a second process (lactate, salicylate, toxic alcohol, renal failure)
›Failure to wake as chemistry improves: CT head for cerebral oedema or stroke, recheck glucose, consider a non-convulsive seizure
›Monitoring cadence
›Capillary or venous glucose hourly
›Venous gas, electrolytes, anion gap, and blood beta-hydroxybutyrate every 2-4 hours until the gap closes
›Continuous cardiac monitoring; hourly neurological observations in children and in the obtunded
Potassium, phosphate, magnesium, and bicarbonate
›Potassium replacement in the adult
›Potassium below 3.3 mmol/l
›Hold insulin; give potassium chloride 20-30 mmol/hr intravenously via a monitored line until 3.3 mmol/l or above
›Peripheral concentration up to about 40 mmol/l; faster or more concentrated infusions need central access and continuous ECG
›Potassium 3.3-5.2 mmol/l
›Add 20-30 mmol potassium chloride to each litre of fluid to keep potassium 4-5 mmol/l
›Potassium above 5.2 mmol/l
›Give none; recheck in 2 hours once insulin and fluids have started
›Renal impairment and dialysis
›Replace potassium more cautiously and recheck it hourly
›Insulin and potassium effects are prolonged; anticipate later hypoglycaemia and rebound hyperkalaemia
›Phosphate
›Replace only for phosphate below 0.3 mmol/l, or with respiratory depression, cardiac dysfunction, or symptomatic anaemia
›Potassium phosphate 20-30 mmol added to fluids, counted within the potassium total
›Recheck calcium because over-replacement causes hypocalcaemia
›Magnesium
›Replace for magnesium below 0.8 mmol/l, refractory hypokalaemia, or a prolonged QT
›Magnesium sulfate 2 g intravenously over 1 hour (about 8 mmol)
›Sodium bicarbonate
›Consider only for venous pH below 6.9 (ADA)
›Sodium bicarbonate 100 mmol in 400 ml sterile water with 20 mmol potassium chloride, infused over 2 hours
›Recheck pH and potassium after the infusion and stop once pH reaches 7.0
›Routine use worsens hypokalaemia, causes paradoxical CSF acidosis, and is linked to cerebral oedema in children
Managing hypoglycaemia from insulin over-delivery
›Stop the source first
›Disconnect and remove the pump because a running or mis-programmed pump keeps delivering
›Suspect bolus stacking, a programming error, or an automated-delivery algorithm acting on a false sensor value
›Conscious and able to swallow
›15-20 g of fast-acting oral carbohydrate; recheck glucose in 15 minutes and repeat until above 4 mmol/l
›Follow with a longer-acting carbohydrate snack once above 4 mmol/l
›Impaired consciousness or unable to swallow, with intravenous access
›Dextrose 10% 100-250 ml intravenously (10-25 g), or dextrose 50% 25-50 ml intravenously
›Recheck at 10-15 minutes and start a 10% dextrose infusion if hypoglycaemia recurs
›No intravenous access
›Glucagon 1 mg intramuscularly or subcutaneously in an adult, or nasal glucagon 3 mg
›Less effective with depleted glycogen (alcohol, malnutrition, prolonged fasting)
›Anticipate a prolonged course
›Rapid analog acts for 4-6 hours; a large stacked bolus or an already-given bridging long-acting dose extends the risk
›Observe with repeat glucose every 30-60 minutes until stable off dextrose for at least 4 hours
›Refractory hypoglycaemia
›Confirm the pump is truly removed; run continuous 10% dextrose; check for adrenal insufficiency, sepsis, and renal failure
›Paediatric dextrose and glucagon dosing: see the Pediatrics subsection
Infusion-site infection and iatrogenic-harm review
›Non-purulent cellulitis at the site
›Remove the set; cephalexin 500 mg orally four times daily for 5-7 days (covers streptococci and methicillin-sensitive S. aureus)
›Mark the border and review at 48 hours
›Purulent infection or abscess
›Incision and drainage, then cover methicillin-resistant S. aureus
›Trimethoprim-sulfamethoxazole 160/800 mg (one to two double-strength tablets) orally twice daily, or doxycycline 100 mg orally twice daily
›Systemic signs or rapid spread
›Cefazolin 2 g intravenously every 8 hours
›Add vancomycin 15-20 mg/kg intravenously every 8-12 hours (target trough 15-20 mg/l or AUC-guided) if MRSA risk or sepsis
›Necrotising soft-tissue infection
›Piperacillin-tazobactam 4.5 g intravenously every 6 hours plus vancomycin plus clindamycin 900 mg intravenously every 8 hours, with urgent surgical debridement
›Iatrogenic-harm review for routine interventions this patient may receive
›Insulin through the failed pump or cannula: contraindicated because the site may not absorb; use a fresh site or the intravenous route
›Intubation: avoid; if unavoidable set a high ventilator rate to match respiratory compensation and expect peri-intubation acidaemia and hypotension
›Ketamine 1-2 mg/kg intravenously for induction and rocuronium 1.2 mg/kg intravenously
›Avoid suxamethonium (1-1.5 mg/kg intravenously) if the potassium is high
›Sedation: propofol 1-2 mg/kg or midazolam 0.05-0.1 mg/kg intravenously worsen hypotension and blunt respiratory compensation; gastroparesis raises aspiration risk
›Fluid loading: excessive or rapid fluid is linked to cerebral oedema in children and pulmonary oedema in adults; titrate to perfusion
›Oxygen: only for measured hypoxaemia; Kussmaul breathing is compensatory, not hypoxic
›Vasopressors: hypotension is almost always hypovolaemic and pressors mask under-resuscitation; use only for refractory shock after adequate volume
›Mechanical circulatory support including intra-aortic balloon pump: not indicated; the problem is volume and electrolytes, not cardiac pump failure
›Anticoagulation: ketoacidosis is prothrombotic; avoid routine central lines in children (catheter thrombosis and stroke), give standard VTE prophylaxis in admitted adults, and do not give empirical therapeutic anticoagulation
›Fibrinolysis: no role; image a focal deficit before attributing it to metabolic derangement
›Analgesia: opioids mask an evolving surgical abdomen and worsen ileus; reassess pain after metabolic correction
›Acetaminophen 1 g intravenously or orally every 6 hours (maximum 4 g/day, or 3 g/day with hepatic impairment or low body weight)
›Avoid NSAIDs such as ibuprofen 400 mg orally given volume depletion and prerenal azotaemia
›Antiemetics: ondansetron 4 mg intravenously prolongs the QT; check the QTc and replace magnesium and potassium first