II. Indications
III. Contraindications
- Severe Diabetic Ketoacidosis (pH <7.0, serum bicarbonate <10 mmol/L)
- Altered Level of Consciousness (e.g. stupor or coma)
- Significant Electrolyte abnormalities
IV. Precautions
- Correct Hypokalemia prior to Insulin Dosing
- Fluid administration is central to DKA treatment
V. Protocol: Adults
- See Diabetic Ketoacidosis Management in Adults
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General
- Use subcutaneous Rapid-Acting Insulin (Lispro, Aspart)
- Fluids and Electrolytes
- Coadminister fluids as per Diabetic Ketoacidosis
- Initial Intravenous Fluid bolus (1-2 L NS or LR)
- Maintenance fluids at 150 ml/hour
- Do not start Insulin until Serum Potassium is at least >3.5 mEq/L
- Monitor serum electolytes, Serum Ketones, and Venous Blood Gas every 4 hours
- Coadminister fluids as per Diabetic Ketoacidosis
- Dextrose solution is added when Blood Glucose <250 mg/dl
- Blood Glucose 200 to 250 mg/dl: Add D5W 100 ml/h
- Blood Glucose 150-199 mg/dl: Add D5W 150 ml/h
- Blood Glucose 100-149 mg/dl: Add D5W 200 ml/h
- Blood Glucose <100 mg/dl: Add D5W 250 ml/h, provider notified and hold Insulin
- Treat Hypoglycemia (Glucose <70 mg/dl)
- Hourly SQ Insulin Protocol (with hourly bedside Glucose)
- Initial SQ bolus dose: 0.2 to 0.3 units/kg (other protocols start with 0.1 unit/kg)
- Next: 0.1 units/kg/hour SQ until Hyperglycemia corrects (Blood Glucose <250 mg/dl)
- Next: 0.05 units/kg/hour SQ until DKA resolves (Anion Gap closed to <16)
- Discontinue hourly dosing when Glucose 150-200
- Every 2 hour SQ Insulin Protocol (with every 2 hour bedside Glucose)
- Initial SQ bolus dose: 0.2 to 0.3 units/kg
- Next: 0.2 units/kg every 2 hours SQ until Hyperglycemia corrects (Blood Glucose <250 mg/dl)
- Next: 0.1 units/kg every 2 hours SQ until DKA resolves (Anion Gap closed to <16)
VI. Protocol: Children
- See Diabetic Ketoacidosis Management in Children
- Precautions
- SQ Insulin for DKA Management is less established in children
- Blood Glucose every 2 hours
-
General
- Use subcutaneous Rapid-Acting Insulin (Lispro, Aspart)
- Coadminister fluids as per Diabetic Ketoacidosis
- Monitor serum electolytes, Serum Ketones, and Venous Blood Gas every 4 hours
- Every 2 hour SQ Insulin Protocol
- Give 0.1 to 0.15 units/kg every 1-2 hours
- Decrease dosing as Hyperglycemia corrects (Blood Glucose <250 mg/dl)
VII. Efficacy
- As effective and safe as Insulin Infusion
- Advantage over Insulin Infusion
- May be monitored on regular medical ward (non-ICU)
- Reduced cost by 39% compared with infusion