DKA Treatment with IV Infusion
For DKA treatment using IV infusion, start continuous regular insulin at 0.1 units/kg/hour (after an initial bolus of 0.1 units/kg in adults) combined with aggressive fluid resuscitation at 15-20 ml/kg/hour initially, while maintaining serum potassium ≥3.3 mEq/L before initiating insulin. 1
Initial Fluid Resuscitation
- Begin with isotonic saline (0.9% NaCl) at 15-20 ml/kg body weight/hour for the first hour 1, 2
- After initial resuscitation, continue with 0.45-0.75% saline at rates adjusted to replace total deficits over 24-48 hours 2
- When serum glucose reaches 250 mg/dl, switch to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin to clear ketones 2
Critical pitfall: Do not delay fluid resuscitation—volume depletion correction is as important as insulin therapy for resolving DKA. 2
Insulin Infusion Protocol
Adults
- Give IV bolus of regular insulin at 0.1 units/kg body weight 1
- Follow immediately with continuous IV infusion at 0.1 units/kg/hour 1, 2
- Target glucose decline of 50-75 mg/dl/hour 1, 2
Pediatric Patients
- Do NOT give initial insulin bolus 2
- Start continuous infusion at 0.05-0.10 units/kg/hour 2
- For neonates, use 0.05 units/kg/hour 2
If glucose does not fall by 50 mg/dl in the first hour, double the insulin infusion rate every hour until steady decline is achieved. 2
Potassium Management (Critical Priority)
Before Starting Insulin
- Absolutely do not start insulin if serum potassium <3.3 mEq/L—this can cause life-threatening cardiac arrhythmias and death 1, 3
- If K+ <3.3 mEq/L, hold insulin and aggressively replace potassium first 1
- Obtain ECG to assess cardiac effects of hypokalemia 1
During Treatment
- Once renal function is confirmed and K+ ≥3.3 mEq/L, add 20-40 mEq/L potassium to each liter of IV fluid 1, 3
- Use combination of 2/3 KCl (or potassium-acetate) and 1/3 KPO4 2, 3
- Maintain serum potassium between 4-5 mEq/L throughout treatment 3
Critical pitfall: Insulin drives potassium intracellularly, and acidosis correction further lowers serum potassium—both create risk for life-threatening hypokalemia, arrhythmias, or cardiac arrest. 3
Monitoring Requirements
- Check blood glucose every 1-2 hours initially 1
- Draw blood every 2-4 hours for: serum electrolytes (especially potassium), venous pH, blood urea nitrogen, creatinine, and osmolality 2, 1, 3
- Monitor mental status closely to identify changes suggesting cerebral edema 2
Measure β-hydroxybutyrate (not nitroprusside ketones) to monitor ketoacidosis resolution, as nitroprusside only measures acetoacetic acid and can falsely suggest worsening ketosis during treatment. 2
Bicarbonate Therapy Decision
- No bicarbonate is necessary when pH ≥7.0—insulin therapy alone is sufficient 3
- Consider bicarbonate only if pH <6.9: give 100 mmol sodium bicarbonate in 400 ml sterile water at 200 ml/hour 3
- Even for pH 6.9-7.0, studies show no benefit in morbidity or mortality 3
Common pitfall: Do not give bicarbonate based on low HCO3 alone—pH is the determining factor. Bicarbonate can worsen hypokalemia and increase risk of cerebral edema. 3
Resolution Criteria
Continue IV insulin infusion until ALL of the following are met: 3
- Glucose <200 mg/dl
- Serum bicarbonate ≥18 mEq/L
- Venous pH ≥7.3
Transition to Subcutaneous Insulin
- When DKA resolves and patient can eat, start multiple-dose subcutaneous insulin schedule 1
- Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping IV insulin—this is the most common error leading to DKA recurrence 1
- Continue IV insulin for 2-4 hours after giving subcutaneous basal insulin to prevent rebound hyperglycemia and ketoacidosis 1
Special Considerations for Pediatric Patients
- Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements (typically 5 ml/kg/hour) 2, 1
- Do not exceed two times maintenance requirements to avoid cerebral edema risk 2
- Monitor particularly closely for cerebral edema—a rare but devastating complication more common in children 2