DKA: What to Do When Standard Insulin Infusion Fails to Meet Metabolic Targets
In diabetic ketoacidosis, initial management with intravenous fluid resuscitation and a fixed-rate intravenous insulin infusion does not always achieve the required metabolic response. When monitored targets are not being met, a defined escalation step applies.
Previous Treatment — Failure Condition
The preceding line — fixed-rate intravenous insulin infusion (FRIII) with intravenous fluid resuscitation — is considered to have failed when the following targets are not reached:
- Blood ketones falling by at least 0.5 mmol/L/hour
- Venous bicarbonate rising by at least 3.0 mmol/L/hour
- Plasma glucose falling by at least 3.0 mmol/L/hour
Failure to maintain potassium within target range or persistent acidosis at 24 hours also indicates inadequate response.
Next-Line Approach — Partial Overview
When the above targets are not being met, the protocol requires first confirming that the insulin delivery equipment is functioning correctly, then escalating the insulin infusion rate in structured increments. The complete sequence — including how rate adjustments are timed, verified, and when to involve a prescribing clinician — is detailed in the full protocol.
Treatment Targets
- Blood ketones falling by at least 0.5 mmol/L/hour
- Venous bicarbonate rising by at least 3.0 mmol/L/hour
- Plasma glucose falling by at least 3.0 mmol/L/hour
References
- If blood ketone measurement is available and blood ketones are not falling by at least 0.5 mmol/L/hr, call a prescribing clinician to increase the insulin infusion rate by 1.0 unit/hr increments hourly until the ketones are falling at target rates (also check infusion).
- If equipment working but response to treatment is inadequate, increase insulin infusion rate by 1 unit/hr increments hourly until targets achieved.
- Reduction of the blood ketone concentration by 0.5 mmol/L/hour.
- Increase the venous bicarbonate by 3.0 mmol/L/hour.
- Reduce capillary blood glucose by 3.0 mmol/L/hour.