potassium acetate (or chloride) and potassium phosphate in equal amounts If the initial serum [K+ ] is less than mEq/L, potassium replacement should be initiated promptly; if less than mEq/L, IVF concentrations of K+ of 60 mEq/L or greater may be necessary With the higher concentrations of potassium, the phosphate component must be adjusted not to exceed the maximum allowable phosphate infusion rate If the K+ initial concentration is low, monitoring via an electrocardiogram (ECG) is indicated Phosphate depletion is almost universal in patients with DKA; however, the clinical significance of this reaction remains uncertain As noted earlier, half of the K+ replacement is with potassium phosphate, up to a maximum of 20 mEq potassium phosphate per liter except in the rare situation of severe hypophosphatemia (serum phosphate less than mEq/L) Infusion of excess phosphate results in hypocalcemia, which may be complicated by tetanic seizures Bicarbonate Therapy In retrospective reviews of patients with DKA who developed significant cerebral edema, bicarbonate administration was identified as a significant risk factor ( Table 89.3 ) This may be because the sickest patients are the ones most likely to have received bicarbonate therapy; however, without further clarification of the pathophysiology, bicarbonate therapy is reserved for patients with both severe acidosis (pH