Manejo de la Cetoacidosis Diabética

Protocolo de Infusión Inicial

• Para pacientes adultos con cetoacidosis diabética moderada a severa, la American Diabetes Association recomienda iniciar con un bolo intravenoso de insulina regular a 0,15 unidades/kg, seguido de una infusión continua a 0,1 unidades/kg/hora (aproximadamente 5-7 unidades/hora en adultos) 1
• En pacientes pediátricos con cetoacidosis diabética, la Academia Americana de Pediatría recomienda no utilizar un bolo inicial de insulina; comenzar directamente con una infusión continua a 0,1 unidades/kg/hora 2, 1

Monitorización y Ajustes de la Velocidad

• La American Diabetes Association recomienda monitorizar la glucemia cada 1-2 horas hasta que los valores de glucosa y las tasas de infusión sean estables, luego cada 4 horas 3
• Si la glucemia no disminuye al menos 50 mg/dl desde el valor inicial en la primera hora, se debe verificar el estado de hidratación; si es aceptable, duplicar la infusión de insulina cada hora hasta lograr una disminución constante entre 50-75 mg/dl/hora 1, 3

Administración de Glucosa

• La American Diabetes Association recomienda iniciar infusión de dextrosa (D5W o D10W) cuando la glucemia cae por debajo de 250-300 mg/dl, mientras se mantiene la infusión de insulina para prevenir hipoglucemia y continuar corrigiendo la cetosis 1, 3

Monitorización de Parámetros Clínicos

• La American Diabetes Association recomienda realizar mediciones de electrolitos séricos, glucosa, nitrógeno ureico, creatinina, osmolalidad y pH venoso cada 2-4 horas 1, 4
• La medición directa de β-hidroxibutirato en sangre es el método preferido para monitorizar la resolución de la cetoacidosis 1, 4

Criterios para la Transición a Insulina Subcutánea

• Los criterios de resolución de cetoacidosis diabética son: glucosa <200 mg/dl, bicarbonato sérico ≥18 mEq/l, y pH venoso ≥7,3 5
• Cuando el paciente pueda comer, se debe iniciar un esquema de múltiples dosis de insulina subcutánea combinando insulina de acción corta/rápida e intermedia/prolongada 5, 4

Discontinuation of Insulin Infusion in Diabetic Ketoacidosis

Resolution Criteria

• The American Diabetes Association recommends discontinuing insulin infusion only after DKA has fully resolved, with glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH ≥7.3, and anion gap ≤12 mEq/L, and the patient can tolerate oral intake and subcutaneous basal insulin has been administered 2-4 hours prior to stopping the IV infusion 6
• The resolution criteria for DKA include glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH ≥7.3, and anion gap ≤12 mEq/L, as well as the patient's ability to eat and drink 6, 7

Insulin Administration

• The American Diabetes Association guidelines recommend administering basal insulin 2-4 hours before stopping the IV insulin infusion to prevent rebound hyperglycemia and ketoacidosis recurrence 6
• A multidose subcutaneous insulin regimen combining short/rapid-acting and intermediate/long-acting insulin should be initiated once DKA resolves and the patient can eat, with a starting dose of approximately 0.5-1.0 units/kg/day for newly diagnosed patients 6, 7

Monitoring and Complications

• Blood glucose should be checked every 2-4 hours until stable, and serum electrolytes, particularly potassium, should be monitored as insulin drives potassium intracellularly 6
• The American Diabetes Association recommends continuing insulin infusion even when glucose normalizes, as ketoacidosis resolution requires continued insulin, and warns against hyperglycemia from premature discontinuation of IV insulin without adequate subcutaneous coverage 6, 8
• Hypokalemia can occur due to insulin administration driving potassium intracellularly, and potassium levels should be maintained at 4-5 mEq/L 6, 7

Guidelines for Glucose Monitoring and Dextrose Use After Insulin‑Based Correction

1. Expected Glucose Trajectory After Insulin

• In patients receiving insulin correction, blood glucose typically falls from very high levels (≈ 580 mg/dL) to around 300 mg/dL within 2 hours, reflecting an effective response without overshooting into hypoglycemia【9】【10】.
• The observed decline of roughly 140 mg/dL per hour (e.g., from 580 mg/dL to 440 mg/dL at 1 hour and to 300 mg/dL at 2 hours) lies within the expected range for standard insulin protocols【9】【10】.

2. Thresholds for Initiating Dextrose

• Dextrose (e.g., D10) is indicated only when blood glucose drops below 70 mg/dL (clinical hypoglycemia) or is trending toward ≈ 100 mg/dL in high‑risk patients receiving continuous insulin infusions【10】.

3. Immediate Monitoring Recommendations

• Continue hourly point‑of‑care glucose checks for the next 2–4 hours after insulin administration to verify the trajectory and detect any rapid decline【10】.
• At each glucose check, assess for hypoglycemia symptoms (sweating, tremor, confusion, tachycardia), as symptoms may precede laboratory‑confirmed low glucose【10】.

4. Intervention Criteria for Emerging Hypoglycemia

• If glucose falls below 70 mg/dL, give 15 g of oral carbohydrate (or 25 mL of D50 IV if oral intake is not possible) and re‑measure glucose after 15 minutes【10】.

5. Expected Stabilization Without Additional Dextrose

• With appropriate insulin dosing, glucose is expected to stabilize in the 140–180 mg/dL range over the subsequent 2–4 hours without the need for supplemental dextrose【10】.

6. Ongoing Vigilance Beyond the Initial Period

• Do not discontinue monitoring after 2 hours; insulin’s duration of action is 4–6 hours, and delayed hypoglycemia can occur 2–4 hours post‑dose【10】.
• Nursing staff should be instructed to perform an immediate glucose check if the patient exhibits any hypoglycemia symptoms, rather than relying solely on scheduled measurements【10】.