From the Guidelines
In Diabetic Ketoacidosis (DKA), intravenous fluids should be administered first.
Rationale
- The primary goal in treating DKA is to restore circulatory volume and tissue perfusion, which is achieved by administering intravenous fluids, typically 0.9% NaCl or other crystalloid, at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8-12 hours 1.
- Fluid replacement is crucial to prevent shock, organ failure, and to help reduce glucose levels and ketoacid production.
- Insulin administration should be started after fluid replacement has been initiated, with a typical dose of 0.05 units/kg/h i.v. insulin, to help reduce glucose levels and ketoacid production 1.
- The use of intravenous insulin is the standard of care in critically ill and mentally obtunded individuals with DKA or hyperosmolar hyperglycemia, while subcutaneous rapid-acting analogs may be used in patients with uncomplicated DKA 1.
- It is essential to monitor electrolytes, renal function, venous pH, osmolality, and glucose every 2-4 hours until stable, and to adjust treatment accordingly 1.
The FDA Drug Labels for insulin (IV) do not address this question.
From the Research
Administration of Intravenous Fluids and Insulin in Diabetic Ketoacidosis (DKA)
- The administration of intravenous fluids and insulin in DKA is a critical aspect of treatment, with the goal of normalizing blood glucose levels and correcting acidosis.
- According to the study by 2, the use of a two-bag intravenous fluid system decreased the duration of intravenous insulin therapy, suggesting that fluid administration may be an important initial step in treatment.
- The study by 3 found that the majority of patients (91.3%) received potassium, and hypokalemia was common (41.7%), highlighting the importance of electrolyte management in DKA treatment.
- In terms of insulin administration, the study by 4 found that an initial insulin bolus was associated with significantly more adverse effects, including hypokalemia, without a corresponding benefit in time to resolution of DKA.
- The study by 5 evaluated the feasibility of the two-bag method for treatment of DKA in adults and found that it was associated with earlier correction of acidosis, earlier discontinuation of insulin infusion, and fewer intravenous fluid bags charged.
- The study by 6 found that implementation of a DKA-Power Plan was associated with appropriate discontinuation of intravenous insulin, more frequent administration of subcutaneous insulin prior to discontinuation of intravenous insulin, and fewer episodes of rebound DKA.
Key Findings
- Intravenous fluids should be administered first to correct dehydration and electrolyte imbalances 2, 5.
- Insulin therapy should be initiated after fluid administration, with careful monitoring of blood glucose and electrolyte levels 3, 4.
- The use of a two-bag intravenous fluid system and a standardized treatment protocol may improve outcomes in DKA treatment 2, 5, 6.
- An initial insulin bolus may not be necessary and may increase the risk of adverse effects 4.