 So the mainstay of treatment of the patient that has DKA is fluids, insulin, and potassium. The priority is the rehydration or the fluids. These patients are typically very dehydrated up to six liters behind and so you're going to give leaders of normal saline to restore the uvolemia. And then you can move over to half normal saline. The important point to make here is that by calculating your serum osmolarity in addition to your physical examination findings, you can estimate the degree of volume depletion. Is this a patient that has hypovolemic shock where you will use your normal saline at one liter per hour? Is it just mild to moderate hypovolemia? In which case you are going to evaluate that patient's corrected serum sodium for every 100 milligrams per deciliter of glucose increase over the normal, it will artificially decrease the serum sodium by 1.6 milli equivalents per liter. Or is this a person that is so severely dehydrated that there in cardiogenic shock hemodynamic monitoring is also going to be necessary. But once you have evaluated the corrected serum sodium, if the sodium is increased or if the serum sodium is normal, you may consider starting out after that first liter that we talked about previously with half normal saline. If the sodium is low, then normal saline. But your goal is when the glucose reaches 250 milligrams per deciliter, you can change to D5W half normal saline along with your insulin infusion and to keep the glucose between 150 and 200 milligrams per deciliter. In the administration of the fluids, the sodium load of rehydration can cause a non-ion gap metabolic acidosis, a hypochloremic metabolic acidosis as the underlying gap is closing. And so when you are in your flow chart checking your bicarb, it may not rise above 18 to 20. And that's of no consequence as long as the gap is closing. And we also in administering the fluids have to be ever watchful for a patient that has been being treated for a couple of hours that begins to develop a headache and alteration in middle status because one of the complications of treatment of DKA with the fluids is that too rapid a replacement of that fluid can cause brain swelling and cerebral edema. It's rare, more commonly occurs in children. And when it does occur, it has a very high mortality up to 70%. The treatment is with mannitol. The insulin treatment is not as much to treat the hyperglycemia as it is to stop the acidosis. But before I talk about the insulin treatment, I would like to say that if the potassium is less than 3.3 million equivalents per liter, then you should hold the insulin administration. So you don't start insulin until you check the potassium. And although the patient may present with hyperglycemia or normal potassium, their total body potassium depleted. High serum potassium is fictitious. It's coming from the volume contraction of dehydration and you'll also recall that one of the compensatory responses to acidosis is to kick potassium out of the cell into the accessory, the fluid, in exchange for hydrogen ions. The issue with that is if the potassium is less than 3.3 and you give insulin, you remember that insulin requires potassium to be taken into the cell so that if you administer insulin and the patient is already hypokalemic, then that can result in severe malignant arrhythmias. But the potassium is greater than 3.3 million equivalents per liter, but less than 5.5 million equivalents per liter give 20 to 30 million equivalents of K in the liter of fluid over the same one hour in an effort to keep the potassium between 4 and 5 million equivalents per liter. We're going to use regular insulin, low-dose insulin starting out with an IV bolus, for example, of 0.15 units per kilogram and then regular insulin IV infusion, 0.1 units per kilogram. If the blood glucose does not fall by 50 to 70 milligrams per deciliter in the first hour, you can double the infusion rate hourly until the glucose falls by 50 to 70. Once you reach 250 milligrams per deciliter of glucose, you can change to D5W half normal again. You check your Chem 7 every 2 to 4 hours till the patient is stable when the patient begins eating. You can change them to subcutaneous regular insulin on a sliding scale. So the important thing to remember is that the insulin is to stop the acidosis and not for the hyperglycemia per se. And you're going to continue your insulin until the gap is closed and the ketones have disappeared irrespective of your glucose concentration. If the glucose drops below 200 and the acidosis has not resolved, that's where your D5W half normal comes in at. And so when the gap has closed and the ketones are gone, the patient is ready to eat. There is no more nausea than you can roll over to subcutaneous regular insulin and feed the patient and turn off the drip. So that a little bit more about the potassium, if that potassium when you check it initially is greater than 5.5, you're not going to administer any potassium. Even knowing that the individual is total body potassium depleted, you're going to check it every couple of hours and when it gets between greater than 3.3, but not, excuse me, when it gets greater than 3.3, but not more than 5.5, you can give 20 million equivalents to 30 million equivalents in each liter of fluid. And what you're attempting to do is to keep the potassium between 4 to 5 million equivalents per liter. So that's an overview of the management of the patient with DKA. If there are any questions or comments, please leave them in the comment box below. Thank you very much for watching the video and if you would like to take advantage of our USMLE courses, please use the promo code below.