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.
Results
There were 22 documented cases of DKAs, with a pH on presentation ranging between 6.92 and 7.28. All responded very well to subcutaneous insulin and none had to be switched to IV infusion. All recovered fully within 24 hours of the initiation of treatment, the majority of them within 12 hours. The average stay for the newly diagnosed child presenting with DKA was approximately 56 hours - not significantly different from those newly diagnosed presented without whose length of stay averaged 52 hours. All children settled very well on the ward. Feedback from the nurses, the junior doctors, as well as all consultant paediatricians was very positive, expressing full satisfaction with the outcome achieved and the ease compared with their experience of dealing with IV infusion of insulin.
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.
Solution
Since May 2011, 22 children presented to the local A&E department with moderately severe or severe DKA and pH ranging between 6.92 and 7.28. All were considered to qualify for the subcutaneous insulin approach. Newly diagnosed patients were started on 0.2 unit/kg/hour boluses repeated every 4 hours (this is the same as 0.05 unit/kg/h recommended of IV rate and calculated over 4 hours). Insulin sensitivity was calculated quite accurately within 4 hours of the first injection of insulin in all patients and the team was ready to start accurate basal bolus injections within a few hours of admission. Established diabetics in DKA received a corrective dose of subcutaneous insulin based on their established insulin sensitivity or correction factor, allowing for a maximum correction of 15 mmol/L every 4 hours. All had their hourly blood sugar and 2 hourly blood ketones monitored following the first injection of insulin and those who were severely acidotic had their blood gases and electrolyte monitored 4 hourly until they started to eat and the basal bolus regimen commenced.
Learnings
The main challenge for implementing the initiative was to convince the traditionalists to adopt it. It took a lot of personal efforts: being available for advice 24/7 for all DKA cases, drawing a clear plan and maintaining close supervision on progress were all important. Another important challenge was to make sense of this different approach to junior doctors without compromising what they might have experienced and learned from other units.
Evaluation
The three most important factors in managing newly diagnosed type 1 diabetics - namely glucose sensitivity, insulin sensitivity and insulin carb ratio - are calculated and established in all the cases within 4 hours of admission, allowing education and training to start very quickly and almost certainly leading to shorter length of stay in hospital. Managing DKA with subcutaneous insulin should become the standard practice in all hospitals across the UK: the child and family are happier in a less frightening environment and likely to stay a shorter time in hospital. Nurses are more relaxed and the NHS saves resources not only by saving on HDU/PICU beds but also on reduced length of stay.
