Background

Diabetic ketoacidosis (DKA) is an endocrine emergency. The  standard of care of treating DKA is fluid resuscitation, electrolyte management, and intravenous insulin infusion in the intensive care unit (ICU) setting for close glucose and electrolyte monitoring. Recent research aims at investigating the treatment of DKA with subcutaneous insulin in non-ICU settings. 

 

Clinical Question

Are subcutaneous insulin analogs in mild-to-moderate DKA efficacious, safe, and cost-effective, thus allowing treatment in non-ICU settings?

 

Population

This study occurred in an urban academic hospital with over 90,000 annual visits. Of these, 177 were mild-to-moderate DKA patients, defined as evidence of DKA (hyperglycemia, ketosis, and an anion gap) without severe features (HCO3 < 10 or arterial pH <  7.0). Of this group, 78 patients were placed in the SQuID protocol (subcutaneous insulin in DKA), and 99 were in the traditional cohort. 

 

Intervention

SQuID protocol: IV fluids, electrolyte replacement, POC glucose every two hours, and insulin lispro (subcutaneous short-acting insulin).  Patients were admitted to an inpatient observation unit managed by a hospital medicine service.

 

Control

A total of 99 mild-to-moderate DKA patients were placed in a traditional cohort during the study period.

Prior cases used as a control included 163 pre-intervention and 161 pre-COVID historical control patients.

 

Outcomes

Primary: operational impacts (EDLOS, ICU admission)

Secondary: fidelity, safety

 

Design

A prospective experimental study with retrospective data to evaluate outcome measures. Data was collected from August 1, 2021 – February 20, 2022. Providers screening a patient for DKA were given a Best Practice Advisory to consider placing the patient on SQuID protocol.  Fidelity was examined by the frequency of required q2h glucose checks, safety by seeing how many patients required rescue dextrose for hypoglycemia, and operational impacts including ED LOS and ICU admission. 

Image from cited article.

 

Excluded

  • Patients with severe DKA (HCO3 < 10 mmol/L or arterial pH < 7.0)
  • Patients <18 years of age 
  • Exclusion criteria for the SQuID protocol: 
    • Pregnancy
    • Serious infections
    • Concerns for myocardial infarction
    • Altered mental status
    • Active comorbidities (ESRD, CHF, on immunosuppressants)
    • Need for a surgical intervention
    • ED or inpatient team determined the patient was too ill for the designated floor (an inpatient observation unit run by hospitalist physicians)

 

Primary Results

177 patients with mild to moderate severity DKA (78 SQuID, 99 traditional)

    • 76 were admitted to an ICU
    • Among those admitted to a medical floor:
      • 73 patients were managed on the SQuID protocol 
      • 28 were managed on an insulin infusion 

Fidelity

  • High fidelity for patients in the SQuID pathway

Safety

  • No differences in safety issues in patients in the SQuID pathway compared to the traditional cohort

EDLOS

  • Significantly shorter for patients in the SQuID pathway

ICU admission

  • Reductions in ICU admissions were observed though not statistically significant

 

Strengths

Variety of controls, including pre-COVID, pre-protocol, and current controls. 

 

Limitations

Generalizability (single center, level 1 urban hospital with limited ICU beds available).

Implementation requires a new hospital specific protocol involving provider education and inpatient unit for SQuID protocol.

 

Author's Conclusions

“In this single academic medical center study, subcutaneous fast-acting insulin analogs for the treatment of mild to moderate–severity diabetic ketoacidosis in the ED was effective, demonstrated equivalent safety, and reduced ED length of stay.”

 

Potential Impact To Current Practice

ED boarding continues to be a major nationwide issue, and ICU bed availability is often limited. Implementing a DKA protocol where patients’ safety and fidelity are not compromised and patients can be treated promptly is ideal for both patients and throughput for EDLOS. 

 

Bottom Line

Using subcutaneous fast-acting insulin for diabetic ketoacidosis can be safe for patients with mild to moderate DKA. However, significant medical education and protocol implementations still need to be implemented to practice a protocol like SQuID safely.