Insulin

Insulin is required to normalise blood glucose and suppress ketogenesis. There is evidence that insulin given within the first hour of treatment increases the risk of cerebral oedema. [34-36] Therefore, do NOT start insulin until intravenous fluids have been running for at least an hour. [34]

A continuous low dose IV infusion should be used:                     

50 units of Actrapid® in 50ml of 0.9% saline (1unit/ml solution).

An infusion rate of 0.05units/kg/hour of insulin is likely to be sufficient in most cases. Some local policies may advise commencing insulin at a rate of 0.1units/kg/hour, but there is currently no evidence that one infusion rate is superior to another. The BSPED suggest a starting dose of 0.05Units/kg/hr unless severe DKA or in adolescents.

The infusion rate of the insulin therapy may need to be altered according to glucose levels (see previous section).

Patients who are already on insulin:

• Those who use an insulin pump, the device should be turned off when starting DKA treatment.

• Those who are already on Long Acting Insulin (e.g. Lantus), the long acting insulin may be given subcutaneously at the normal dose & time during DKA treatment.

Your local policy may give advice on when/ if to start long acting insulin concurrently in newly diagnosed diabetics in DKA.