Subcutaneous insulin for DKA safe, efficient, and cost-effective

Summary

Most guidelines still recommend intravenous infusion of insulin as a means of managing uncomplicated diabetic ketoacidosis (DKA), with children on intravenous insulin infusion considered high dependency patients, requiring close monitoring from both nurses and doctors - even though they may be clinically well. The team adopted a different approach, treating them on the general paediatric ward with subcutaneous insulin. This is given to patients who are stable, with evidence of good peripheral perfusion (normal blood pressure, and capillary refill). In 4 years, 22 patients were admitted with moderately severe or severe DKA and all had a good response to insulin. The approach is safe and efficient, improves speed of recovery, reduces hospital length of stay and improves the patients’ and carers’ experience.

Challenge

Until 2011, the paediatric department at St Mary’s Hospital had real difficulties persuading the nursing staff, particularly during busy seasons, to admit DKA patients on IV insulin to the general paediatric wards. As a result, most of our DKAs had to be cared for in high dependency unit (HDU) or paediatric intensive care unit (PICU) settings which meant there was constant pressure on PICU beds. In addition the children and their families were exposed to the stress associated with the environment of the PICU, and also meant that the child stayed significantly longer at hospital.

Objectives

To demonstrate that subcutaneous administration of rapid-acting insulin analogues is as effective and safe as intravenous infusion of regular insulin for the management of uncomplicated DKA – and to show that the use of subcutaneous insulin in the management of DKA is far more compatible with earlier start on training and structured education leading to shorter stay in hospital. To spare the children and their families the extra stress associated with the potentially overwhelming experience of the PICU/HDU. The team also wanted to prove that successful use of insulin analogues in the management of DKA may confer a significant overall cost savings, obviating the need for infusion pumps and PICU admissions, thus sparing these beds for other children.

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