In this episode, I’ll discuss subcutaneous insulin for the treatment of diabetic ketoacidosis (DKA).
Diabetic ketoacidosis (DKA) is a serious condition with high mortality if not treated properly. The usual treatment for DKA involves IV insulin with frequent monitoring. For most hospitals this means admission to the ICU is necessary to provide the appropriate nurse to patient ratio given the intensity of treatment and monitoring.
It is possible that subcutaneous administration of insulin could reduce the acuity of care required for DKA patients and allow for them to be cared for in a general medical unit.
A group of researchers at Kaiser Permanente San Jose Medical Center implemented a subcutaneous insulin protocol for DKA patients and have published their results in JAMA. The study is a retrospective cohort study that includes a pre and post-implementation period.
The study spanned over 20 hospitals and there were over 4000 patients in the pre-implementation group and over 3000 in the post-implementation group.
The protocol involved starting management in the ED with an initial dose of 0.3 units per kg subQ of insulin glargine and 0.3 unit per kg subQ doses of insulin lispro every 4 hours until the glucose dropped below 250 mg/dL. Once out of the ED the lispro dose dropped to 0.2 units/kg subQ. The full protocol is available in table 1 of the study with free full text.
After implementation, 80% of patients were able to start treatment with subQ insulin which was more than a 5-fold increase from the pre-implementation rate.
There was a 57% rate reduction in patients needing ICU admission and a 50% rate reduction in patients being readmitted within 30 days in the post-implementation group.
The authors reported no significant changes in hospital length of stay and rates of death between implementation periods.
The protocol is still a detailed and complex management protocol that requires significant nurse training and engagement. However glucose measures start out every 2 hours and decrease to every 4 hours once the glucose drops below 250 mg/dL, and it is often the need for q1 hour glucose measurements that require the lower nurse to patient ratio that the ICU provides. The published protocol does not list the frequency of electrolyte lab draws and replacement.
This is an exciting study that can potentially free up ICU resources. However I would not expect to start using subQ insulin immediately for DKA as extensive nursing education will be necessary to develop the ability to implement such a protocol on a general medical unit.
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