In Diabetic Ketoacidosis (DKA), do we administer intravenous fluids first or insulin first?

From the Guidelines

In Diabetic Ketoacidosis (DKA), intravenous fluids should be administered first to address severe dehydration and electrolyte imbalances.

Rationale

The primary goal in managing DKA is to restore circulatory volume and tissue perfusion, which can be achieved by administering intravenous fluids, such as 0.9% NaCl or other crystalloids, at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8-12 hours 1.

• This approach helps to rapidly restore blood volume, improve tissue perfusion, and reduce the risk of complications such as acute kidney injury.
• Insulin administration should be started after adequate fluid replacement has been initiated, with a typical dose of 0.05 units/kg/h i.v. insulin 1.
• The use of intravenous fluids and insulin should be guided by careful monitoring of the patient's response, including frequent measurements of blood glucose, electrolytes, and venous pH.
• It is essential to individualize treatment based on a careful clinical and laboratory assessment, as there is considerable variability in the presentation of DKA 1.

Key Considerations

• Fluid replacement: Administer 0.9% NaCl or other crystalloids at a rate that replaces 50% of the estimated fluid deficit in the first 8-12 hours 1.
• Insulin administration: Start insulin after adequate fluid replacement, with a typical dose of 0.05 units/kg/h i.v. insulin 1.
• Monitoring: Frequently measure blood glucose, electrolytes, and venous pH to guide treatment 1.
• Individualization: Tailor treatment to the individual patient's needs based on careful clinical and laboratory assessment 1.

From the Research

Administration of Intravenous Fluids and Insulin in Diabetic Ketoacidosis (DKA)

• The administration of intravenous fluids and insulin is a critical aspect of DKA management, with the goal of correcting dehydration, electrolyte imbalances, and hyperglycemia 2.
• According to the study by 2, crystalloids are favored over colloids for intravenous fluid administration, although the preferred crystalloid and hydration rates remain contentious.
• The same study recommends administering intravenous insulin infusion, with a fixed weight-based regimen preferred over a "sliding scale" approach, although evidence for this is weak 2.
• Another study found that the majority of patients (91.3%) received potassium replacement, and the median time to anion gap ≤12 mmol/L was 8.8 hours 3.
• The "two-bag method" for DKA management, which involves titrating dextrose delivery by adjusting the infusions of two i.v. fluid bags of varying dextrose concentrations, has been shown to be feasible and potentially beneficial in adult ED patients with DKA 4.

Order of Administration

• There is no clear consensus on whether to administer intravenous fluids or insulin first in DKA management.
• However, one study suggests that administering an initial IV insulin bolus before low-dose insulin infusions may obviate the need for supplemental insulin 2.
• Another study found that implementing a standardized DKA protocol, which includes administering subcutaneous insulin ≥1 hour before discontinuing IV insulin, was associated with improved outcomes and reduced episodes of rebound DKA 5.

Key Considerations

• Potassium replacement is imperative in DKA management, although the optimal replacement rate is unclear 2.
• Bicarbonate replacement may be considered in severe metabolic acidosis with pH <6.9, but its use is not universally recommended 2, 3, 6.
• The use of standardized treatment protocols and preprinted order sets may help improve DKA management and patient outcomes 3, 6, 5.