What is the recommended treatment dose for Diabetic Ketoacidosis (DKA)?

DKA Treatment Dosing Protocol

Start continuous intravenous regular insulin at 0.1 units/kg/hour after ensuring serum potassium is ≥3.3 mEq/L, and maintain this infusion until complete resolution of ketoacidosis regardless of glucose levels. 1, 2

Initial Insulin Therapy

• Begin with IV regular insulin at 0.1 units/kg/hour as a continuous infusion for moderate to severe DKA 1, 2
• An initial IV bolus of 0.1 units/kg may be given before starting the continuous infusion 2
• Do NOT start insulin if serum potassium is <3.3 mEq/L - this is an absolute contraindication that can cause life-threatening cardiac arrhythmias and death 1, 2
• For critically ill and mentally obtunded patients, continuous IV insulin remains the standard of care 1

Insulin Dose Adjustment

• If glucose does not fall by 50 mg/dL in the first hour, verify adequate hydration status, then double the insulin infusion rate every hour until achieving a steady decline of 50-75 mg/dL per hour 3, 1
• Target glucose decline rate: 50-75 mg/dL per hour 3, 1
• Continue insulin infusion at ≥0.1 units/kg/hour until ketoacidosis resolves, even if glucose normalizes 4

Fluid Resuscitation Dosing

• Initial fluid bolus: 15-20 mL/kg/hour of isotonic saline (0.9% NaCl) during the first hour (approximately 1-1.5 L in average adults) 1, 2
• Subsequent fluid rate: approximately 1.5 times the 24-hour maintenance requirements (roughly 5 mL/kg/hour) 3, 2
• When glucose reaches 250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin 1

Potassium Replacement Dosing

• If K+ <3.3 mEq/L: Hold insulin, aggressively replace potassium until ≥3.3 mEq/L 1, 2
• If K+ 3.3-5.5 mEq/L: Add 20-30 mEq/L potassium to IV fluids (use 2/3 KCl and 1/3 KPO₄) once adequate urine output confirmed 1, 2
• If K+ >5.5 mEq/L: Withhold potassium initially but monitor closely as levels will drop rapidly with insulin 1
• Target serum potassium: 4-5 mEq/L throughout treatment 1

Alternative Regimen for Mild-to-Moderate Uncomplicated DKA

• Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective and potentially safer than IV insulin for uncomplicated mild-to-moderate DKA 1, 5
• This approach is more cost-effective but should not be used in critically ill or obtunded patients 1

Resolution Criteria and Transition

DKA is resolved when ALL of the following are met:

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap ≤12 mEq/L 1, 5

Critical transition step: Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 2

Monitoring Requirements

• Draw blood every 2-4 hours for serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 3, 1
• Venous pH is adequate for monitoring (typically 0.03 units lower than arterial pH) - repeat arterial blood gases are generally unnecessary 3, 1
• Direct measurement of β-hydroxybutyrate is preferred over nitroprusside method for monitoring ketone clearance 3, 1

Common Pitfalls to Avoid

• Never stop IV insulin when glucose falls below 250 mg/dL - this is the most common cause of persistent ketoacidosis; instead add dextrose to IV fluids and continue insulin 1
• Never stop IV insulin without prior basal insulin administration - this leads to DKA recurrence 2
• Inadequate potassium monitoring and replacement is a leading cause of mortality in DKA 1
• Bicarbonate is NOT recommended for pH >6.9-7.0 as it shows no benefit and may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 1, 5