Insulin administration and DKA... PLZ HELP

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Specializes in CVICU, ER.

I am having a test over this on Tues. One of the study questions is as follows:

A patient is in DKA, which route for insulin administration should be used?

a. SQ

b. IV

I keep finding contradicting answers. Lewis medsurg edition 7 says that "Insulin therapy is witheld until fluid resuscitation is underway. Initially a bolus of insulin is delivered, followed by a continuous infusion."

This does not tell me whether if the bolus of insulin is in IV or Sub Q. Any insight would be greatly appreciated. Thanks

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Specializes in DOU.

You can give a bolus through an IV line. I'd go with IV.

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Specializes in CVICU, ER.
You can give a bolus through an IV line. I'd go with IV.

This was my instinct, but I also have somewhere that SQ injection into the abdomen is desired for quicker response. This however was not in the same context as this question. IV would be the quickest, so it should be desired route, right??? This is just my thinking. Thanks so much.

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Specializes in DOU.

I would look at the interventions listed in your textbook, because that is what your test should reflect. (It seems like mine said IV.)

That being said, at least some sources say that subQ injections are as effective as IV. http://www.medscape.com/viewarticle/484507

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Specializes in Oncology.

In DKA the body is often too dehydrated to respond at all to subq insulin, as the hypovolemia causes blood flow to be shunted away from the subq tissue. IV is definitely the correct answer.

I've also never seen continuous infusions of subq insulin used in a hospital setting except in people already on subcutaneous insulin pumps who's diabetes is stable when they are admitted to the hospital, and are then kept on them.

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Specializes in Pediatric/Adolescent, Med-Surg.

If a pt presents in DKA, they would be on an insulin drip (IV) until they resolved. :)

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Specializes in PNP, CDE, Integrative Pain Management.

IV for sure. In a pediatric type 1 diabetic, 0.1 unit Regular/kg/hr - along with 1.5x maintenance fluids. The rationale: IV doesn't have a time lag for absorption. SQ has a wide variability in absorption rates depending on things like hydration status, lipohypertrophy and scar tissue - results of many injections per day over time. Second: IV insulin drips can be titrated as needed. There is a careful balance of rehydration, correction of electrolyte imbalance, and blood glucose levels. Dropping the glucose too quickly is a problem because of the possibility of rapid fluid shifts. Injected insulin can't be titrated, once its in, its in.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
some sources say that subQ injections are as effective as IV. http://www.medscape.com/viewarticle/484507

This is reserved for uncomplicated DKA.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
In DKA the body is often too dehydrated...

Correct. SubQ absorption is decreased secondary to dehydration.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
IV for sure. In a pediatric type 1 diabetic, 0.1 unit Regular/kg/hr - along with 1.5x maintenance fluids. The rationale: IV doesn't have a time lag for absorption. SQ has a wide variability in absorption rates depending on things like hydration status, lipohypertrophy and scar tissue - results of many injections per day over time. Second: IV insulin drips can be titrated as needed. There is a careful balance of rehydration, correction of electrolyte imbalance, and blood glucose levels. Dropping the glucose too quickly is a problem because of the possibility of rapid fluid shifts. Injected insulin can't be titrated, once its in, its in.

Correct. SubQ insulin (fast-acting lispro for example) has been utilized in pediatric DKA (0.15 U/kg q2h). Ketosis is slow to resolve and sometimes takes several hours. This method is often used on the general floor when ICU admission is not warranted (uncomplicated cases).

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Specializes in Education, FP, LNC, Forensics, ED, OB.
I am having a test over this on Tues. One of the study questions is as follows:

A patient is in DKA, which route for insulin administration should be used?

a. SQ

b. IV

I keep finding contradicting answers. Lewis medsurg edition 7 says that "Insulin therapy is witheld until fluid resuscitation is underway. Initially a bolus of insulin is delivered, followed by a continuous infusion."

This does not tell me whether if the bolus of insulin is in IV or Sub Q. Any insight would be greatly appreciated. Thanks

For this exam, I feel certain your instructor is looking for 'b'; IV.

If you want to clarify the question with him/her regarding "complicated vs. uncomplicated" DKA, I would do this.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

a patient is in dka, which route for insulin administration should be used?

a. sq

b. iv

do not read into these questions. yes, there are a number of things going on with dka that need correction:

  • dehydration

  • acidosis and hypokalemia

  • hyperglycemia

however, dka is a
life-threatening
situation. any one of those 3 conditions can cause the death of the patient. the question is specifically asking you "
which route for insulin administration should be used
". one of the goals of treating dka is to get the blood sugar down to normal levels asap.

what is the fastest way to get insulin into circulation? intravenously. "iv injection offers the fastest means of drug absorption because the drug is delivered directly into the circulation; therefore, the onset of drug action is almost immediate." (page 17,
pharmacology: an introduction
, 5th edition, by henry hitner and barbara nagle) that is a principle of drug administration and pharmacology. subcutaneous administration of drugs requires drug absorption (the entrance of the drug into the blood stream) to occur. with subcutaneous administration, a drug must first be dissolved in body fluids and pass through membranes before it finally makes its way into the blood stream, and that takes time. in a crisis situation like dka that time just isn't available to you.

the merck manual also discusses the treatment of dka (
http://www.merck.com/mmpe/sec12/ch158/ch158c.html
) and very specifically states, "hyperglycemia is corrected by administering regular insulin 0.15 unit/kg iv bolus initially, followed by continuous iv infusion of 0.1 unit/kg/h in 0.9% saline solution." it goes on to set some parameters but never waivers in its statement that the insulin be given by any other means except intravenously. another site (my favorite) called family practice notebook (
http://www.fpnotebook.com/endo/dm/dbtcktcdsmngmntinadlts.htm
) gives the physician management protocol for dka. look at this page, as it is quite interesting. it focuses on the physician treating dka in 3 phases:

  • phase 1 - correcting the fluid deficit

  • phase 2 - correcting the electrolyte imbalances

  • phase 3 - correcting the hyperglycemia

and, if you look closely, it is all done
intravenously
. this patient is going to be in a hospital er or an ambulance where this equipment is going to be available.

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