Insulin Therapy for DKA

• Correction of insulin deficiency (A):  Dose: 0.1 U/kg per hour (A)  Route of administration: IV (A)
• The dose of insulin should remain at least 0.1 U/kg per hour at least until resolution of ketoacidosis (pH: >.30; HCO3: >5 mmol/L and/or closure of anion gap). To prevent an unduly rapid decrease in plasma glucose concentration and possible development of hypoglycemia, glucose should be added to the IV fluid when the plasma glucose falls to ∼14 to 17 mmol/L (250–300 mg/dL) (B).
• There may be circumstances in which the insulin dose may be safely reduced earlier, but the criteria have not been defined (E).
• If biochemical parameters of ketoacidosis (pH and anion gap) do not improve, reassess the patient, review insulin therapy, and consider other possible causes of impaired response to insulin (eg, infection, errors in insulin preparation, or adhesion of insulin to tubing with very dilute solutions) (E).
• There is evidence that an IV bolus of insulin is not necessary80,81 (C). However, a bolus may be used at the start of insulin therapy, particularly if insulin treatment has been delayed (E).
• In unusual circumstances in which IV administration is not possible, the intramuscular or subcutaneous route of insulin administration has been used effectively76 (C). However, poor perfusion will impair absorption of insulin.79