• Restoration of fluids and electrolytes is the first resuscitative priority due to dehydration and sodium depletion. Initial hydration rapidly corrects plasma volume and increases the efficacy of later insulin therapy. Intracellular potassium depletion may be masked by near normal or slightly elevated serum potassium levels, especially in a volume-depleted patient. Therefore, following initial rehydration, insulin administration is also accompanied by titrated intravenouspotassium with careful electrolyte measurements. Volume expansion and insulin administration usually resolves the metabolic acidosis from ketoacid production.
  • HbA1c: The major form of glycohemoglobin, termed hemoglobin A1c normally comprises only 4-6% of total hemoglobin. It would be higher in chronically hyperglycemic patients due to condensation of glucose with free amino acids on the globin component of hemoglobin.
  • Maximal insulin effect is reached with plasma levels of 20-200 u/ml. This can be accomplished (ideally in an intensive care setting) by administering IV insulin with an initial bolus of 10-15 units, followed by a continuous infusion at a rate of 2-10 units/hour. The ketoacidotic patient generally presents with decreased intravascular volume, requiring volume expansion and not fluid restriction. Although serum potassium is commonly elevated by ketoacidotic shift from intracellular fluids, total body potassium is often decreased and insulin can rapidly drop serum potassium to dangerously low levels. Often, potassium is judiciously given IV with insulin to keep serum potassium at a safe level.