How to manage a patient with diabetic ketoacidosis (DKA) on an insulin drip with variable glucose levels and an increasing anion gap?

Management of DKA with Variable Glucose Levels and Increasing Anion Gap

For patients with diabetic ketoacidosis (DKA) on insulin drip experiencing variable glucose levels and increasing anion gap, continue the insulin infusion while adding dextrose to maintain glucose between 150-200 mg/dL until complete resolution of ketoacidosis. 1

Assessment and Monitoring

• Evaluate for possible causes of persistent or worsening ketoacidosis despite insulin therapy, including infection, inadequate insulin dosing, or interruption of insulin therapy 1, 2
• Monitor blood glucose, electrolytes, venous pH, and anion gap every 2-4 hours until stable 3
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA resolution, as nitroprusside methods only measure acetoacetic acid and acetone 3

Insulin Management

• Continue intravenous insulin infusion despite variable glucose levels, as ketonemia typically takes longer to clear than hyperglycemia 3, 2
• Do not interrupt or discontinue intravenous insulin therapy when glucose levels fall, as this is a common cause of persistent or worsening ketoacidosis 1
• When glucose falls below 200-250 mg/dL, add dextrose to the hydrating solution while continuing insulin infusion 1

Glucose Management Algorithm

• For glucose <200 mg/dL: Add D5W or D10W to IV fluids while maintaining insulin infusion at 0.05-0.1 units/kg/hour 1
• Target glucose between 150-200 mg/dL until DKA resolution (pH >7.3, bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) 1, 3
• If glucose fluctuates significantly, consider adjusting the insulin rate rather than stopping insulin completely 2

Fluid Management

• Continue aggressive fluid resuscitation with 0.9% NaCl at a clinically appropriate rate 1, 4
• Adjust fluid rate based on hemodynamic status, urine output, and electrolyte levels 1

Electrolyte Management

• Monitor potassium levels closely, as insulin administration can cause hypokalemia 1
• Ensure adequate potassium replacement to maintain serum K+ between 4-5 mmol/L 1
• Check electrolytes, renal function, venous pH, and glucose every 2-4 hours until stable 1, 3

Resolution Criteria

• DKA resolution requires all of the following: 3
  • Glucose <200 mg/dL
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH >7.3
  • Anion gap ≤12 mEq/L

Transition to Subcutaneous Insulin

• Only transition to subcutaneous insulin after complete resolution of DKA 3
• Administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis 1, 3
• Continue intravenous insulin infusion for 1-2 hours after starting subcutaneous insulin 3

Common Pitfalls to Avoid

• Premature discontinuation of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 4, 2
• Inadequate dextrose administration alongside insulin in DKA with lower glucose levels can perpetuate ketosis 4
• Overzealous treatment with insulin without glucose supplementation can lead to hypoglycemia 1
• Interruption of insulin infusion is a common cause of persistent or worsening ketoacidosis 1, 2

Remember that resolution of DKA requires correction of the metabolic acidosis and ketosis, not just normalization of blood glucose. Continuing insulin therapy with appropriate glucose supplementation is essential for complete resolution of DKA and improved patient outcomes 1, 3.