Metabolic Acidosis in Diabetic Ketoacidosis: What to Do When Initial Continuous IV Insulin Fails to Reach Correction Targets

This protocol applies to patients with metabolic acidosis in the context of diabetic ketoacidosis, specifically where capillary blood ketones exceed 3 mmol/L in association with hyperglycaemia — a recognised diagnostic threshold for DKA.

An initial regimen of continuous intravenous insulin was started. After the first hours of treatment, the required correction targets were not achieved: blood ketones were not falling at 0.5 mmol/L/h, bicarbonate was not rising at 3 mmol/L/h, and capillary blood glucose was not decreasing at 3 mmol/L/h. This failure to meet targets is the trigger for the next management step.

The approach at this stage involves a modification to the intravenous insulin regimen, contingent on confirmation of a specific laboratory condition. The complete clinical decision algorithm, safety criteria, and full management sequence are available in the structured protocol.

Success is defined by achieving: correction of blood ketones at 0.5 mmol/L/h, bicarbonate at 3 mmol/L/h, and capillary blood glucose at 3 mmol/L/h.