What is the protocol for initiating an insulin (Regular Insulin) drip for the treatment of Diabetic Ketoacidosis (DKA)?

From the Guidelines

To start an insulin drip for diabetic ketoacidosis (DKA), begin with regular insulin at 0.05 units/kg/hour IV, as recommended by the most recent guidelines 1. For a 70kg patient, this would be approximately 3.5 units per hour.

• Mix 100 units of regular insulin in 100mL of normal saline (1 unit/mL)
• Before starting the infusion, flush 30mL through the tubing to saturate binding sites
• Monitor blood glucose hourly and adjust the rate to achieve a decrease of 50-75 mg/dL per hour
• Once glucose reaches 200-250 mg/dL, reduce the insulin rate to 0.02-0.05 units/kg/hour and add dextrose to IV fluids to prevent hypoglycemia
• Continue the insulin drip until the anion gap normalizes and ketosis resolves, even if blood glucose normalizes earlier
• Simultaneously, provide aggressive fluid resuscitation with normal saline and potassium replacement as needed
• Regular monitoring of electrolytes, especially potassium, is essential as insulin drives potassium into cells, potentially causing hypokalemia This approach effectively lowers blood glucose while clearing ketones through insulin's action on inhibiting lipolysis and promoting glucose utilization, as supported by recent guidelines 1. Some older studies suggest starting with a higher dose of insulin, such as 0.1 units/kg/hour 1, but the most recent guidelines recommend a lower starting dose of 0.05 units/kg/hour 1. It's also important to note that the insulin dose may need to be adjusted based on the patient's individual response to treatment and their underlying medical conditions. Overall, the key to successful management of DKA is to provide prompt and effective treatment with insulin and fluids, while closely monitoring the patient's condition and adjusting the treatment plan as needed.

From the FDA Drug Label

For intravenous use, Humulin R U-100 should be used at concentrations from 0.1 unit/mL to 1 unit/mL in infusion systems with the infusion fluids 0.9% sodium chloride using polyvinyl chloride infusion bags.

To start an insulin drip for DKA, intravenous administration of Humulin R U-100 is possible under medical supervision with close monitoring of blood glucose and potassium levels to avoid hypoglycemia and hypokalemia. The initial dose can be set at 0.5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL), as seen in the study 2.

• Key considerations include:
  • Using concentrations from 0.1 unit/mL to 1 unit/mL
  • Using 0.9% sodium chloride as the infusion fluid
  • Close monitoring of blood glucose and potassium levels
  • Adjusting the dose to maintain normoglycemia 2

From the Research

Starting an Insulin Drip for DKA

To initiate an insulin drip for the treatment of Diabetic Ketoacidosis (DKA), several key points must be considered:

• The primary goal is to safely and effectively manage the patient's hyperglycemia and metabolic acidosis.
• According to 3, an initial insulin bolus prior to a continuous infusion may not be necessary and could potentially lead to more adverse effects, such as hypokalemia.
• The management of DKA involves hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event, as outlined in 4.
• Insulin therapy is a mainstay of treatment, but the optimal dose and administration method are still debated, as discussed in 3 and 5.
• Key considerations for starting an insulin drip include:
  • Restoration of circulating volume
  • Insulin therapy
  • Electrolyte replacement
  • Treatment of any underlying precipitating event, as mentioned in 6 and 7
• Monitoring of the patient's clinical and laboratory states is crucial to adjust the treatment plan as needed and prevent complications.

Key Components of Insulin Drip Management

• Fluid resuscitation: Aggressive intravenous fluids are essential to restore circulating volume and improve blood pressure.
• Insulin administration: Regular insulin is typically used, and the dose is adjusted based on the patient's glucose levels and response to treatment.
• Electrolyte replacement: Potassium, sodium, and other electrolytes must be replaced as needed to prevent deficiencies and complications.
• Monitoring: Close monitoring of glucose levels, electrolytes, and acid-base status is necessary to adjust the treatment plan and prevent complications, as emphasized in 4 and 7.