Evidence-based On-call

Diabetic ketoacidosis

Therapy

Give soluble insulin ^a in low-doses (e.g. 5 to 10 units per hour) ^a

intravenously ^d at regular intervals or continuously ^d

An insulin infusion regimen ^d

Add 50 units of actrapid (soluble) insulin to 50 ml of 0.9% saline. Infuse using the following sliding scale.

The regimen may need to be adjusted depending on your patient’s response.

Why?

A low-dose insulin regimen is less likely to cause hypoglycaemia or hypokalaemia than a high-dose one. ^a
There is no clear difference in the time taken to return to biochemical normality. ^a

A low-dose insulin regimen reduces the risk of hypoglycaemia or hypokalaemia

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
diabetic ketoacidosis ^a	low-dose insulin	high-dose insulin	hypoglycaemia mol/l) at 12 hours	25%	100%	4 (2 to 13)
			hypokalaemia (< 3.4 mmol/l) at 12 hours	29%	86% (-7% to 98%)	4 (2 to 19)

The route used to administer insulin in patients has no clear effect on the time taken to return to biochemical normality or the amount of insulin required. ^d
A continuous insulin infusion is not clearly more likely to cause a faster fall in glucose levels nor shorten the time to reach a glucose <14 mmol/l than a bolus followed by regular injections. ^d