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TABLE 89.2 PRINCIPLES OF MANAGEMENT OF DIABETIC KETOACIDOSIS Life-threatening complications Cerebral edema Cardiovascular collapse Profound metabolic acidosis Hyperkalemia Hypokalemia Hypophosphatemia Areas of management decisions • Fluids Treat hypovolemia with crystalloid extracellular fluid expander Use normal saline (0.9%) and infuse 10 mL/kg in the first 1–2 hrs (Avoid hypotonic solutions initially because they are inefficient volume expanders and may contribute to cerebral edema.) Continue infusion at this rate until perfusion is improved and urine output is reestablished After first 1–2 hrs, start half-normal saline—use greater tonicity, up to normal saline, if the initial serum sodium is less than 135 mmol/L or if the serum sodium falls with therapy Total fluid administration in first 48 hrs should rarely exceed one and one-half to two times maintenance • Alkali Avoid bicarbonate therapy in DKA Only consider if arterial pH