359 Evaluation of Insulin Infusion Rates for the Treatment of Diabetic Ketoacidosis in the Emergency Department

Abstract

There is currently minimal literature to support the dosing rate for the initiation of intravenous (IV) insulin therapy in DKA. We sought to assess descriptive characteristics for IV insulin prescribing for DKA management within the emergency department. A predictive regression model was applied to test if predefined lab values influenced the starting insulin infusion rates. Clinical and safety outcomes were evaluated based on starting insulin infusion rate. A retrospective cohort study was conducted within an academic emergency department and included patients who received continuous infusion regular insulin with an ICD-10 code for DKA during the same encounter between January 2016 and January 2019. Descriptive analysis was completed for baseline population characteristics. Chi-squared test was used to analyze categorical variables and the student’s t-test or kruskai wallis for continuous data using SAS. Data was analyzed based on both DKA severity (mild, moderate, or severe) and starting insulin infusion rates <0.07 units/kg/hr, 0.07-0.099 units/kg/hr, 0.1-0.139 units/kg/hr, and ≥0.14 units/kg/hr. Hypoglycemia and hypokalemia were defined by documented ICD-10 codes within 0 to 48 hours of starting insulin therapy. 347 patients met inclusion criteria with 92 (26.5%) patients in the <0.07 units/kg/hr cohort, 123 (35.4%) patients in the 0.07 to 0.099 units/kg/hr cohort, 123 (35.4%) patients in the 0.10 to 0.139 units/kg/hr cohort, and 9 (2.6%) patients in the ≥0.14 units/kg/hr cohort. Patient demographics and outcomes are shown in table 1. After adjusting for baseline lab values, glucose was the only significant predictor of the initial infusion rate (p<0.05). For every 100 mg/dL increase in the baseline glucose value, the initial infusion rate increased by 0.005 units/kg/hr. A higher anion gap was correlated with a higher initial infusion rate and a higher bicarbonate and pH were correlated with a lower initial infusion rate, though not statistically significant. There is a wide range of starting insulin infusion rates utilized. Glucose levels significantly influenced the insulin starting infusion rate, with no identified differences in adverse effects or clinical outcomes between starting infusion rate cohorts.