A client is receiving a continuous IV infusion of regular insulin for DKA. The blood glucose has decreased from 480 to 310 mg/dL over the past 2 hours. At what blood glucose level should the nurse add dextrose to the IV fluids?

DKA MANAGEMENT requires a critical understanding of why insulin therapy continues even after blood glucose normalises.

The DKA principle: DKA is resolved when the anion gap normalises and ketones are cleared — NOT simply when blood glucose returns to normal. The insulin infusion is the treatment for the ketoacidosis, not just the hyperglycaemia.

Dextrose addition protocol: When blood glucose falls to 200-250 mg/dL (typical threshold), dextrose 5% or 10% is added to the maintenance IV fluid; this prevents hypoglycaemia while the insulin infusion continues at a reduced rate to resolve the ketoacidosis; the insulin must continue until the anion gap closes and bicarbonate normalises; WITHOUT dextrose addition: continuing insulin without dextrose when glucose reaches 200 mg/dL would cause hypoglycaemia before the acidosis is resolved.

Stopping insulin too early: If insulin is stopped when glucose normalises but before ketosis resolves, the underlying metabolic problem is not treated and DKA will rebound. MONITORING PARAMETERS DURING DKA TREATMENT: Blood glucose every 1-2 hours; BMP every 2-4 hours (anion gap, bicarbonate, potassium, creatinine); strict I&O; vital signs every 1-4 hours; mental status.

Potassium replacement: Critical — insulin drives potassium into cells, causing hypokalaemia; potassium must be checked before starting insulin; hold insulin if K+ below 3.5 mEq/L and replace first.