DKA is a very common endocrine emergency that we encounter very frequently in the ED in both pediatrics and adults. Standard therapy of care includes IVF, correction of electrolyte disturbances, +/- bicarb, and of course insulin. Prior to starting the insulin drip many providers administer an insulin bolus with the thought that it will overcome the relative insulin deficiency seen in DKA in order to suppress lypolysis and gluconeogenesis which in turn will limit or reduce further acidosis. But is there any benefit to this? And could this potentially be harmful to the patient?
Two prospective studies have addressed this very question and in conclusion have demonstrated collectively that administration of the insulin bolus was not shown to reduce time to glucose normalization, pH or bicarb levels, change the rate of anion gap, or reduce the length of hospital stay. In fact the study conducted by Goyal et al actually found administration of the bolus to be harmful. At the end of that study there was a 6% incidence of profound hypoglycemia in patients who received the insulin bolus compared to 1% in those who did not receive the bolus.
Bottom line: There is no benefit to administration of an insulin bolus prior to starting the insulin drip in DKA patients. The bolus could potentially worsen hypoglycemia and further disrupt electrolyte imbalances