Management of DKA using insulin exclusively through the subcutaneous route is safe, acceptable, and can have system-level benefits. As protocolized care has improved the quality of care of patients with DKA, it is critical to adapt institutional protocols to ensure safe implementation of subcutaneous pathways.
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ACEP Now: Vol 42 – No 10 – October 2023
Dr. Westafer (@Lwestafer) is an attending physician and research fellow at Baystate Medical Center, clinical instructor at the University of Massachusetts Medical School in Worcester, and co-host of FOAMcast.
References
- Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343.
- ElSayed NA, Aleppo G, Aroda VR, et al. Diabetes care in the hospital: standards of care in diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S267-S278.
- Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, et al. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Libr. 2016;2016(1).
- Rao P, Jiang SF, Kipnis P, et al. Evaluation of outcomes following hospital-wide implementation of a subcutaneous insulin protocol for diabetic ketoacidosis. JAMA Netw Open. 2022;5(4):e226417.
- Griffey RT, Schneider RM, Girardi M, et al. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. Acad Emerg Med. 2023;30(8):800-808.
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One Response to “Subcutaneous Insulin for Diabetic Ketoacidosis”
October 22, 2023
David Whitten, MD, PhD, FACEPIn the long ago days, prior to about 1974, DKA was usually treated with large bolus IV injections of regular insulin – up to 100 unit boluses, along with replacement fluids and electrolytes. Studies showing the efficacy of low dose continuous infusions appeared at about the same time as other studies showing the efficacy of low dose intramuscular injections of insulin R. In my experience in emergency medicine I have successfully treated and discharged patients from the ER using both intermittent SQ insulin and IM insulin along with appropriate fluid and electrolyte infusions. Most hospitals mandate ICU admission and have a more-or-less rigid insulin infusion protocol, but when the ICU is full I have found it feasible to treat and discharge non-critically ill DKA patients in the ER.