Daily Bolus of LR: Insulin in DKA

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May 19, 2011 by dailybolusoflr

Insulin therapy in DKA is aimed at lowering serum glucose and at slowing ketone production.


         The standard regimen for using insulin in patients with moderate to severe DKA has been to provide patients with a bolus of regular insulin (0.1 units/kg) IV followed by an infusion at a dose of 0.1 units/kg/hour.

         Recent literature supports this as an acceptable method but also proposed an “infusion only” method. 

         This method uses an infusion alone at a rate of 0.14 units/kg/hour.  Rates below this do not given the same efficacy and should not be used if you are using the infusion only method.


Timetable guidelines for Insulin therapy:

         Lower the serum glucose by at least 50-75 mg/dL per hour

         If this is not obtained after the first hour, the rate should be doubled every hour until a steady decline is noted

         When the serum glucose reaches 200 mg/dL, the insulin infusion rate can be decreased to 0.02-0.05 units/kg/h and dextrose should be added to the IVF

         IV insulin should be stopped only AFTER transition to subcutaneous insulin has begun with an overlap of at least an hour (ie. given the patients home dose of NPH 1 hour before stopping the insulin drip)

o   If insulin is stopped before subcutaneous (long acting) insulin has been given, recurrent hyperglycemia and acidosis may occur


o   WHEN should you transition?

§  When ketoacidosis has resolved

         This criteria is met when the serum glucose is < 200 mg/dL AND

         Two of the following are met:

o   Bicarb ≥ 15mEq/L

o   pH > 7.3

o   Calculated Anion Gap ≤ 12 mEq/L



Diabetes Care, 2009; 32(7):  1335-1343.

Diabetes Care. 2008;31(11):2081-2085.




Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions


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