In a patient with diabetic ketoacidosis receiving a continuous insulin infusion who becomes hypoglycemic, how should the hypoglycemia be managed?

Management of Hypoglycemia During Insulin Infusion in DKA

When a DKA patient develops hypoglycemia during insulin infusion, do NOT stop the insulin—instead, immediately add dextrose to the IV fluids while continuing the insulin infusion at the same rate to allow ongoing ketone clearance. 1, 2

Immediate Actions

• Administer 10–20 g of intravenous dextrose (20–50 mL of 50% dextrose or 100–200 mL of 10% dextrose) titrated to the initial hypoglycemic value, aiming to raise blood glucose above 70 mg/dL without causing rebound hyperglycemia 3, 4
• Recheck blood glucose in 15 minutes and repeat dextrose administration as needed until glucose stabilizes above 70 mg/dL 3, 1
• Continue the insulin infusion without interruption because ketoacidosis resolution requires sustained insulin therapy regardless of glucose levels 1, 2, 5

Transition to Dextrose-Containing Fluids

• Switch IV fluids to 5% dextrose with 0.45–0.75% saline (D5W with half-normal or three-quarter-normal saline) when plasma glucose falls to approximately 250 mg/dL, while maintaining the insulin infusion rate 3, 1
• In euglycemic DKA (initial glucose <250 mg/dL), start dextrose-containing fluids from the outset of insulin therapy 1
• The goal is to maintain plasma glucose in the 150–200 mg/dL range until complete resolution of ketoacidosis (pH ≥7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) 1

Insulin Infusion Management

• Never discontinue or reduce the insulin infusion when glucose normalizes—this is a critical error that prevents ketone clearance and can precipitate rebound ketoacidosis 1, 2, 6
• If hypoglycemia occurs despite dextrose supplementation, the insulin infusion rate may be reduced to 0.05–0.1 U/kg/hour (approximately 4–6 U/hour in adults) but should never be stopped entirely 1, 2
• In severe, refractory DKA, insulin infusion rates of 4–6 U/hour or higher may be required with appropriate glucose supplementation to prevent hypoglycemia while clearing ketones 1, 7

Monitoring Protocol

• Check blood glucose every 1–2 hours during active insulin infusion until glucose and infusion rates are stable, then every 2–4 hours 1, 2
• Monitor serum electrolytes (especially potassium), venous pH, bicarbonate, and anion gap every 2–4 hours until metabolic stability is achieved 3, 1
• Measure serum potassium before each insulin dose adjustment because insulin drives potassium intracellularly, and severe hypokalemia (<2.5 mEq/L) is associated with increased mortality 3, 1

Potassium Management During Hypoglycemia Correction

• Maintain serum potassium at 4.0–5.0 mEq/L throughout DKA treatment by adding 20–30 mEq/L potassium to IV fluids (using 2/3 potassium chloride or acetate and 1/3 potassium phosphate) 1
• Hypoglycemia correction with dextrose does not eliminate the need for ongoing potassium replacement, as insulin continues to shift potassium intracellularly 1

Common Pitfalls to Avoid

• Do NOT stop insulin when glucose falls—this is the most frequent error in DKA management and prevents resolution of ketoacidosis 1, 2, 6
• Do NOT rely on urine ketones alone to assess ketoacidosis resolution, as they lag behind serum ketone clearance; direct measurement of β-hydroxybutyrate in blood is preferred 1, 2
• Do NOT prematurely discontinue IV insulin before administering subcutaneous basal insulin 2–4 hours earlier, as this causes rebound hyperglycemia and recurrent DKA 3, 1, 6, 8
• Do NOT use 50% dextrose routinely for hypoglycemia correction in DKA, as it can cause overcorrection and higher post-treatment glucose levels; instead, use 10% dextrose in 50-mL (5-g) aliquots repeated every minute until symptoms resolve 1

Resolution Criteria and Transition

• DKA is considered resolved when all of the following criteria are met: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2
• Administer subcutaneous basal insulin (glargine or detemir) 2–4 hours before stopping the IV insulin infusion to prevent rebound hyperglycemia and ketoacidosis recurrence 3, 1, 2, 6, 8
• Continue IV insulin for 1–2 hours after the subcutaneous basal dose to ensure adequate absorption 3, 1