From the Guidelines
I recommend continuing the D10 infusion at 50 ml/hr while initiating subcutaneous insulin therapy, as the patient's glucose has stabilized from the initial critical level of 10 mg/dL to a safer range (113-155 mg/dL), indicating successful initial management. The patient's history of DKA and current glucose levels suggest the need for careful management to prevent recurrent hypoglycemia and hyperglycemia. According to the most recent guidelines, initiating insulin therapy is crucial in managing DKA, and subcutaneous insulin therapy can be started once the patient is stable 1.
The patient's current glucose levels, ranging from 113 to 155 mg/dL, are within a safer range, but close monitoring of blood glucose levels every 4-6 hours is necessary to adjust the D10 infusion rate and insulin doses accordingly. If glucose falls below 100 mg/dL, consider increasing the D10 rate to 75-100 ml/hr temporarily, and if glucose exceeds 200 mg/dL consistently, reduce the D10 rate and adjust insulin doses accordingly.
Key considerations in managing this patient include:
- Monitoring blood glucose levels closely to adjust treatment as needed
- Maintaining adequate hydration and electrolyte balance
- Gradually transitioning from intravenous to subcutaneous insulin therapy
- Preventing complications such as cerebral edema, hypokalemia, and hyperchloremia
By following these guidelines and closely monitoring the patient's condition, the risk of morbidity and mortality can be minimized, and the patient's quality of life can be improved 1.
From the Research
Patient Management
- The patient has a history of diabetic ketoacidosis (DKA) and currently has a blood sugar level of 155, which was previously 113 after receiving 500ml of D10 sugar 2, 3.
- The patient is currently on D10 50ml/hr, and the blood sugar level needs to be managed to prevent further complications 4, 5.
- The treatment of DKA involves fluid and electrolyte replacement, insulin therapy, and treatment of the underlying precipitating event 2, 3, 4.
Laboratory Tests and Monitoring
- Electrolytes, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, A1C, and electrocardiography should be evaluated to identify causes and complications of DKA 4.
- Additional tests such as amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography may be considered 4.
Insulin Therapy and Transition
- The patient's insulin therapy should be adjusted based on their blood sugar levels and the presence of ketones 3, 5.
- The transition from intravenous to subcutaneous insulin should be considered when the patient's anion gap is ≤12 mEq/L, but the success of this transition may not be affected by the anion gap level 6.