A 24-year-old woman with type 1 diabetes mellitus is admitted to the intensive care unit with diabetic ketoacidosis. She is initiated on appropriate intravenous normal saline, potassium replacement, and a continuous regular insulin infusion. Her initial blood glucose is and anion gap is .
Arrange the following monitoring and therapeutic steps in the correct chronological sequence required to safely transition this patient off intravenous insulin.
- 1Add dextrose to the intravenous fluid replacement when capillary blood glucose reaches .
- 2Document the resolution of ketoacidosis by confirming an anion gap of and venous pH .
- 3Administer a subcutaneous dose of long-acting basal insulin once the patient is able to tolerate oral intake.
- 4Discontinue the continuous intravenous regular insulin infusion to hours after the subcutaneous injection.
Answer
The correct sequence involves first adding dextrose when glucose falls to prevent hypoglycemia, followed by confirming anion gap closure. Once the gap is closed, subcutaneous insulin is administered, and finally, the IV insulin is discontinued after a 1-to-2-hour overlap.
The correct sequence prioritizes maintaining the insulin infusion to close the anion gap while managing the dropping glucose levels by adding dextrose. Once the gap closes, a safe transition requires overlapping the new subcutaneous insulin dose with the IV drip for to hours to prevent rebound ketoacidosis.
Step-by-Step Solution
Key Concept
Resolution of DKA requires continuous insulin until the anion gap closes; dextrose is added to prevent hypoglycemia, and subcutaneous insulin must overlap with the IV infusion for to hours before discontinuation.