The SQuiD Is Back! Subcutaneous Insulin for DKA

October 28, 2024

Written by Vivian Lei

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SQuID is effective in managing DKA, with improvements in time to anion gap closure and ED length-of-stay compared to intravenous insulin protocols.

SQuID II
Management of diabetic ketoacidosis (DKA) is complex and can strain resources when ICU care is not immediately available, leading to prolonged ED stays. This study expands upon the use of the SQuID protocol (subcutaneous insulin in DKA) implemented at Barnes-Jewish Hospital to evaluate the effectiveness and operational impact of the protocol for a sicker cohort of patients with low- to moderate-severity diabetic ketoacidosis (LTM DKA).

In this study of 84 patients with LTM DKA, researchers compared outcomes of those treated with subcutaneous insulin (SQuID) versus traditional intravenous (IV) insulin. The median age of participants was 45 years, with 57% male and 75% identifying as Black/African American. SQuID was used in 74% of cases and 26% received IV insulin.

Clinical effectiveness was demonstrated by a shorter time to anion gap closure by 1.4 hours and shorter median time on protocol by 10.3 hours in the SQuID group compared to IV insulin. Safety outcomes were similar, with a lower but nonsignificant incidence of rescue dextrose for hypoglycemia in the SQuID group. Operational effectiveness was demonstrated by shorter emergency department length of stay (EDLOS) for SQuID patients (median 9.8 hours) compared to 18.3 hours in those receiving IV insulin being admitted to the floor, although the small sample size of the IV group limited statistical significance. Compared to the pre-SQuID period, the rate of ICU admissions for LTM DKA patients dropped by about 33%.

While the study was limited by its single-center implementation and low sample sizes, it reaffirms that a subcutaneous insulin protocol for treatment of DKA is clinically effective and reduces ICU usage for LTM DKA patients.

How will this change my practice?
I see a clear role for subcutaneous insulin treatment of DKA in settings where ICU beds are scarce and would like to see future studies that address the use of SQuID protocol in different hospital settings, especially in rural or smaller facilities where patient transfers to higher-level centers might be avoided.

Editor’s note: I don’t feel this study shows us much of anything by way of their comparisons since their protocols made SQuID the default. It does demonstrate that SQuID is working for them, but otherwise the comparisons are hollow. ~ Nick Zelt

Source
SQuID (subcutaneous insulin in diabetic ketoacidosis) II: Clinical and operational effectiveness. Acad Emerg Med. 2024 Sep 23. doi: 10.1111/acem.15020. Epub ahead of print. PMID: 39308229.