Lit Matters 1: Subcutaneous Insulin: Can it be Used for the Treatment of DKA?

Mild to moderate diabetic ketoacidosis does not always require an ICU insulin drip. Selected adults can be managed with a structured subcutaneous insulin pathway, with shorter ED length of stay and similar safety in this SQuID protocol study.

Subcutaneous Insulin for Mild DKA

• Selected patient population: The signal applies to mild to moderate DKA, not severe disease; altered mental status, pregnancy, serious infection, ESRD, CHF, and other active comorbidities were key reasons patients were kept out of the pathway.
• Operational outcome signal: A structured SQ insulin pathway shortened emergency department length of stay to 8.9 hours versus 11.9 hours with traditional IV insulin management, a meaningful systems result when boarding is the real bottleneck.
• Safety comparison: Hypoglycemic events were not significantly different between SQ and IV strategies, supporting SQ insulin as a feasible alternative when the patient is otherwise appropriate for non-ICU care.
• Monitoring feasibility: The protocol used every-2-hour glucose checks and performed comparably to traditional hourly monitoring, a practical detail with major implications for observation-unit workflow. We get into the operational tradeoffs in the episode.
• Automated pathway trigger: One notable design feature was an electronic trigger: glucose over 300 mg/dL prompted point-of-care ketones, and elevated ketones then launched a broader DKA workup and pathway activation.
• Implementation reality: Adopting an SQ DKA pathway is a hospital-wide process involving ED clinicians, pharmacy, and inpatient teams; IV and SQ insulin are not mutually exclusive, and earlier basal SQ insulin may fit alongside infusions in selected cases.