Subcutaneous Insulin for DKA Management

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1: Introduction to Subcutaneous Insulin for DKA
- Diabetic ketoacidosis (DKA) is a serious condition with significant morbidity and mortality risks.
- Evidence supports treating mild to moderate DKA with subcutaneous (SQ) insulin regimens.
- SQ insulin can decrease the need for ICU admission without increasing adverse events.

Diagnostic Criteria
- Hyperglycemia: Blood glucose above 250 mg/dL.
- Ketonemia: Positive serum or urine ketones.
- Acidosis: Arterial pH below 7.3 or bicarbonate below 15 mEq/L.

Severity Classification
- Mild: pH 7.25-7.30, bicarbonate 15-18 mEq/L.
- Moderate: pH 7.00-7.24, bicarbonate 10-15 mEq/L.
- Severe: pH below 7.00, bicarbonate below 10 mEq/L.

2: Patient Selection for SQ Insulin in DKA
- Suitable for patients with isolated DKA without other ICU requirements.
- Appropriate for mild to moderate severity DKA cases.
- Patients still require aggressive fluid replacement and electrolyte monitoring.

3: Management Approach
- Aggressive fluid replacement is essential.
- Frequent point-of-care and basic metabolic panel monitoring is required.
- Aggressive electrolyte repletion is necessary.
- Underlying precipitating causes of DKA must be treated.

4: Insulin Protocol
- Start insulin dosing only after adequate electrolyte repletion.
- Initial dose: Long-acting insulin (glargine) 0.2 to 0.3 units/kg SQ or patient's home dose.
- Initial dose: Fast-acting insulin (aspart/lispro) 0.3 units/kg SQ.
- Subsequent dosing depends on serum glucose levels.

5: Subsequent Insulin Dosing
- For serum glucose above 250 mg/dL: Short-acting insulin 0.2 units/kg every 2-4 hours.
- For serum glucose below 250 mg/dL: Short-acting insulin 0.1 units/kg every 2-4 hours OR sliding scale insulin every 4 hours.

6: Benefits and Considerations
- SQ insulin protocol is supported by the American Diabetes Association.
- Helpful in managing bed shortages and ED boarding situations.
- Long-acting insulin dose given every 24 hours (or restart patient's home regimen).
- Short-acting insulin given every 2 to 4 hours.

7: Key Takeaways
- SQ insulin is a viable alternative for mild to moderate DKA management.
- Patient selection and close monitoring are crucial for success.
- Aggressive IV fluid resuscitation remains a cornerstone of DKA management.
- Electrolyte repletion and addressing underlying causes are essential components of treatment.

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