8725 Subcutaneous Compared With Intravenous Insulin Protocol For Management Of DKA: A Longitudinal Experience In A Single Center
Authors: Avula Sreekant , Salim Michael , Wetherbee Erin , Wenner Carrie , Gravely Amy , Westanmo Anders D , Ercan-Fang Nacide G 
Published: October 2024

Abstract
Disclosure: S. Avula: None. M. Salim: None. E. Wetherbee: None. C. Wenner: None. A. Gravely: None. A.D. Westanmo: None. N.G. Ercan-Fang: None.
Background: Diabetic ketoacidosis (DKA) is a critical condition requiring immediate medical attention to prevent severe health complications and even death. Typically, patients are placed under the care of the intensive care unit (ICU) to ensure close supervision. With implementation of effective subcutaneous insulin protocol (SIP), patients can be safely managed outside of ICU without any significant change in mortality or morbidity, potentially decreasing financial burden of costly ICU stay. Aim: To review and compare the experience with subcutaneous and intravenous insulin protocols for management of DKA at Minneapolis Veterans Affairs Health Care System (MVAHCS). Methods: We conducted a retrospective chart review of patients who were admitted with DKA at MVAHCS from 2013 - 2023 and were treated with either I.V insulin or SIP. Inclusion criteria: Adults (age &gt;/=18 years) admitted with DKA between 2013 and 2023. Exclusion criteria: Non availability of VBG/ABG and patients who were not treated initially at MVAHCS. Statistical analysis used was basic descriptive analysis, Pearson’s Chi-Square and Two sample T test. Results: Majority of patients included were males: 57 (96.61%) and 16 (88.89) in SIP and I.V insulin, respectively. Racial distribution of patients was skewed towards a white population: Total of 57 (74.03%) were white, 12 (15.58%) were African American (AA). A significant majority of white patients 47 (79.66%) were on SIP, while 10 (55.56%) were on I.V insulin. Mean age of SIP and I.V insulin study populations were 58.9 (SD 16.21) and 59.2 years (SD 12.23), respectively. Baseline mean pH of the SIP and I.V insulin study populations were 7.27 (SD 0.08) and 7.13 (0.13), respectively. Mean bicarb for SIP was 14.9 mEq/L (SD 4.60) and I.V Insulin was 10.1 mEq/L ( SD 4.57). Mean time for anion gap (AG) closure among patients on SIP was modestly higher at 19.7 hours (SD 15.3) when compared to that on I.V insulin of 17.1 hours (SD 12.4) but the difference did not reach statistical significance. Similarly, 55.6% (n=10) of patients on I.V insulin and 58.6% (n=34) of those on SIP had anion gap closure of &gt;/= 12 hours (p = 0.8187). When adjusted for baseline pH and bicarbonate, 46% of patients in the I.V insulin group had AG closure &gt;=12 hours, whereas 67% of those in the SIP group had AG closure &gt;=12 hours with total difference of 21% (p= 0.2098). Conclusion: Our results demonstrate that SIP can be safely implemented outside of the ICU setting. Compared with SIP, baseline pH was slightly less in the IV group (our protocol directs sicker patients with lower baseline pH towards the I.V insulin rather than SIP), however, AG closure time was similar between the two groups even after performing multiple regression analysis where we adjusted for baseline differences between two treatment groups in pH, bicarbonate, AG. These results indicate that SIP could be safe and potentially cost saving alternative for DKA management.
Presentation: 6/3/2024