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