Do Not Restart the DKA Insulin Drip
Your patient has met resolution criteria for DKA and should be transitioned to subcutaneous insulin rather than restarting the IV insulin infusion. 1
Resolution Criteria Assessment
Your patient's current parameters indicate DKA resolution:
- Bicarbonate 20 mEq/L - exceeds the resolution threshold of ≥18 mEq/L 1
- Anion gap 17 mEq/L - while slightly elevated above the resolution target of ≤12 mEq/L, this is approaching normal and consistent with resolving acidosis 1
- Blood glucose 215 mg/dL - slightly above the <200 mg/dL resolution target but acceptable 1
- Ketones 0.29 mmol/L - significantly improved and approaching normal (<0.5 mmol/L) 1
The American Diabetes Association defines DKA resolution as: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, and venous pH >7.3 1. Your patient has achieved the bicarbonate threshold, which is the most critical metabolic parameter.
Appropriate Next Steps
Transition to Subcutaneous Insulin
Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping any remaining IV insulin infusion to prevent rebound hyperglycemia and recurrent ketoacidosis. 2 This is the most common error leading to DKA recurrence - stopping IV insulin without prior basal insulin administration 2.
Continue Monitoring
- Check blood glucose every 2-4 hours while the patient remains NPO 2
- Continue monitoring electrolytes, particularly potassium, as insulin drives potassium intracellularly 2
- The slightly elevated anion gap (17 mEq/L) and glucose (215 mg/dL) will normalize with subcutaneous insulin therapy 1
Critical Pitfall to Avoid
Do not restart the IV insulin drip based solely on mild residual hyperglycemia or a slightly elevated anion gap when bicarbonate has normalized. 1 The ketones at 0.29 mmol/L indicate near-complete resolution of ketoacidosis 1. Ketonemia typically takes longer to clear than hyperglycemia, and persistent mild elevation does not warrant restarting aggressive IV insulin therapy 1.
Why Restarting Would Be Inappropriate
- The metabolic acidosis has resolved (bicarbonate 20 mEq/L) 1
- Continuing IV insulin at this stage increases hypoglycemia risk without additional metabolic benefit 3
- The patient requires transition to a sustainable outpatient insulin regimen, not escalation of acute therapy 2
Special Consideration
If the patient cannot eat yet, start a multiple-dose subcutaneous insulin schedule using short/rapid-acting and intermediate/long-acting insulin combinations 2. Ensure structured discharge planning includes patient education on insulin administration, glucose monitoring, and sick day management to prevent DKA recurrence 2.