In this episode, I’ll discuss subcutaneous insulin therapy for patients with low to moderate severity DKA.
When a patient with DKA is treated with a continuous IV infusion of insulin, this requires a high level of nursing care to safely monitor. Often this means the patient is in a ICU-level of care even if they might not otherwise seem critically ill. In some hospitals that lack enough ICU capacity, a patient with less severe DKA might be held in the Emergency Department and treated there until they no longer require IV insulin and qualify for a regular medical floor.
In the past several years, retrospective research has explored whether a cohort of patients with less than severe DKA might be effectively treated with subcutaneous rather than continuous insulin therapy. Such a strategy has the inherent advantage of not requiring admission to a unit with a low nurse-to-patient ratio to implement safely, thus lowering the burden of caring for a patient with DKA. This research has mostly focused on patients with low to moderate severity DKA but has not resulted in widespread use of subcutaneous insulin in this patient population. A group of researchers have recently published in Academic Emergency Medicine a prospective, observational cohort study looking at highlighting the effectiveness of their subcutaneous insulin protocol to treat DKA in a real-world setting.
Data from 84 ED patients with low to moderate severity DKA were analyzed. About three-quarters of the population received a subcutaneous insulin protocol referred to as SQuID (standing for subcutaneous insulin in DKA) and one-quarter received IV insulin. Most of the IV insulin group were treated in the ICU. All of the SQuID group patients were treated on a general medical unit.
Compared to those treated with IV insulin, the SQuID group had a shorter time median until anion gap closure (1.4 hrs less) and a shorter median time on protocol (10.3 hrs less). Both of these improvements were statistically significant in favor of the SQuID group.
The SQuID protocol had a lower percentage of patients that required rescue dextrose administration for hypoglycemia. However this 10% absolute difference in favor of the SQuID group did not reach statistical significance.
At the center where this protocol has been used, the ICU admission rate for patients with non-severe DKA has decreased from 54% pre-protocol to under 21%.
The protocol is published in the supplemental material for the study. It involves checking point-of-care glucose values every 2 hours, a basic metabolic panel every 4 hours, and using fast-acting insulin lispro. Insulin is not given unless the serum potassium is at least 3.5 mEq/L. If the blood glucose is over 250 mg/dL, insulin lispro 0.2 units/kg is given subcutaneously. At the first blood glucose value under 250 mg/dL the dose is reduced to 0.1 units/kg and IV dextrose 5% is started at a rate dependent on the blood glucose. Subcutaneous insulin doses and D5W rate adjustments continue every 2 hours until the anion gap is 16 or lower, at which time the provider is contacted to transition the patient off the protocol.
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