Subcutaneous Insulin in the Treatment of Diabetic Ketoacidosis in the Pediatric Population

Background: Diabetic ketoacidosis or DKA is an acute and fatal disease that is highly prevalent in the pediatric population. The current gold standard of treatment is continuous intravenous regular insulin (CIRI), which requires admission to the intensive care unit (ICU) and is a substantial cost to the patient. Alternate routes of insulin administration, such as subcutaneous (SQ) insulin, do not require ICU admission. If SQ insulin is found to be safe and efficacious for the treatment of DKA, this treatment modality could replace continuous IV regular insulin, and therefore decrease the need for ICU admission and cost of stay. Methods: An exhaustive search of available medical literature was performed using MEDLINE – Ovid, MEDLINE - PubMed, Web of Science, Google Scholar, and CINAHL. Keywords included: diabetic ketoacidosis or DKA, subcutaneous insulin, intravenous insulin, and pediatric. Eligible studies were assessed using the GRADE criteria. Results: Two articles met inclusion criteria and were included for this systematic review. One study was a retrospective chart review and the other a randomized controlled clinical trial. The retrospective chart review looked at 76 instances of DKA and found that median time to DKA resolution was 10.3 hours using SQ insulin. The controlled clinical trial randomly assigned 30 patients to receive CIRI and 30 patients to receive SQ insulin. Patients receiving SQ insulin took up to 6 hours longer to achieve full DKA resolution as compared to the CIRI group. However, in both studies, patients that were treated with SQ insulin experienced no increase in adverse outcomes including hypokalemia, hypoglycemia, cerebral edema, or death. Conclusion: Subcutaneous insulin, regular or fast acting, can be used as a safe and effective treatment of DKA in pediatric patients. Providers should consider administration of SQ insulin every 4 hours if using regular insulin and every 2 hours if using fast-acting insulin analogs until DKA resolution. Keywords: Diabetic ketoacidosis, subcutaneous insulin, and pediatric patient