From the Guidelines
For a patient with diabetic ketoacidosis (DKA) who has unstable glucose levels despite receiving bolus insulin, the next best step is to start a continuous intravenous infusion of regular insulin at a dose of 0.1 unit kg–1 h–1. This approach is based on the recommendation from the study published in Diabetes Care 1, which suggests that continuous intravenous infusion of regular insulin is the treatment of choice for DKA, especially when the episode is not mild. The initial bolus of regular insulin at 0.15 units/kg body weight can be followed by a continuous infusion, but if plasma glucose does not fall by 50 mg/dl from the initial value in the 1st hour, the insulin infusion may be doubled every hour until a steady glucose decline between 50 and 75 mg/h is achieved, as suggested by the study 1. Key considerations for managing DKA include:
- Monitoring hydration status and adjusting the insulin infusion rate accordingly
- Direct measurement of ketones to monitor the resolution of ketoacidosis
- Avoiding initial insulin bolus in pediatric patients and starting continuous insulin infusion when plasma glucose reaches specific thresholds The use of continuous intravenous insulin infusion allows for more consistent and titratable insulin delivery, which is crucial for managing unstable glucose levels in DKA patients.
From the FDA Drug Label
Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency)
The next best step for a patient with Diabetic Ketoacidosis (DKA) who has unstable glucose levels despite receiving bolus insulin is to seek medical assistance immediately. The patient should be evaluated for possible causes of hyperglycemia, such as inadequate insulin dosing, infection, or other stressful situations, and treated accordingly 2.
From the Research
Next Best Step for Diabetic Ketoacidosis Management
The next best step for a patient with Diabetic Ketoacidosis (DKA) who has unstable glucose levels despite receiving bolus insulin is to consider alternative insulin administration protocols.
- The use of an initial insulin bolus prior to a continuous infusion has been associated with significantly more adverse effects, such as hypokalemia, without a corresponding benefit in time to resolution of DKA 3.
- A study comparing two protocols of intravenous insulin therapy found that both protocols were safe and had comparable efficiency in the management of DKA, with no significant differences in time to recovery or complications 4.
- The management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event, as well as frequent monitoring of the patient's clinical and laboratory states 5.
Insulin Administration Protocols
- The preferred method of insulin administration in DKA is intravenous infusion of regular human insulin, with or without an initial bolus 6.
- Fixed weight-based insulin infusions are recommended over "sliding scale" insulin infusions, although evidence is weak 6.
- Upon resolution of DKA, subcutaneous insulin is recommended, with IV insulin infusions ceased with an overlap of 1-2 hours 6.
Considerations for DKA Management
- DKA management lacks strong evidence due to the absence of large randomized controlled trials (RCTs) 6.
- Current practice is guided by weak evidence and consensus opinion, and all aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes 6.
- Early diagnosis and management are paramount to improve patient outcomes, and the mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 7.