Vincent article: Treatment of DKA with sq lispro
– How has reading the article changed your practice?
This article has not completely changed my practice, but I would like to look further into whether some of our more straight-forward DKA patients could potentially be placed in step down with q2h lispro injections, especially when we are short on critical care beds.
– What information had you believed in previously that were debunked by reading this article?
I previously believed that DKA patients needed to be on insulin drips because that was the only easily titratable regimen. This article would argue, however, that lispro can be just as easily started and stopped accordingly.
– What new information did you learn from reading this article?
I learned the fast onset of action and the short duration of action of lispro that would make it a possible candidate as a replacement for a regular insulin drip. In comparison, I did not realize how long it took for an injection of regular insulin to reach its effect.
– What are current areas of uncertainty on this topic that can be potential areas for research?
One thing I found interesting was that this study was sponsored by Eli Lilly, who makes lispro and regular insulin. They mention at one point that lispro is more expensive than regular insulin and argue that overall costs would be lowered if the patient did not have to be in the ICU, but I wonder whether they would still end up profiting if this change was made widespread. Maybe I’m just cynical and paranoid, but possible ulterior motives are at least something to be aware of.
I also have a concern that the SC insulin review by Vincent et al included mostly smaller randomized studies (only 156 in all). Perhaps the power of these studies even combined may not be able to detect small differences in complication rates compared to standard insulin drip.
But certainly I think it’s completely reasonable to put people in stepdown with mild or moderate DKA on SC insulin at this time. Like Andy Ulrich says, “there’s a hospital attached to our emergency department”!
As for the Mcphee Etomidate article, the methodology is pretty strong especially for a retrospective article. It’s good example of being able to glean a lot of useful information and reach some level of conclusion with a large study database if randomized controlled trials are difficult.
However, my beef is that it included only ICU intubations. My concern is that perhaps their entire patient population weren’t sick enough to need intubation in the ED? Or perhaps the patients aren’t the same as the ones we’re treating.
It is interesting that their etomidate group was even sicker and did just as well.
Nevertheless, the literature goes back and forth on this and in my opinion, it is currently just as acceptable to use etomidate as it is to choose a different agent.
Considering alternatives such as ketamine that does not blunt the blood pressure, it is certainly reasonable to use it for now until further research puts this to rest.
How has reading the article changed your practice?
At Lahey, the other day I had a 21 y/o gentleman, new-onset diabetes dx in mild DKA. I discussed with Brandon Libby (former BMC resident) this article and managing the patient with sq insulin. We tried it for a bit until Endocrinology recommended insulin gtt. I think it’s a perfectly reasonable strategy for the “softer” DKA patients (i.e. ones you’d put on the floor)
– What information had you believed in previously that were debunked by reading this article?
I had no idea there was “mild” DKA. I thought if you had DKA, it was severe. I thought IV insulin lasted a lot longer than “a half life of9 minutes”
– What new information did you learn from reading this article?
I had no idea that DKA could be managed with sq insulin prior to getting the patient’s glucose <250. The fact that there are multiple papers showing similar effect to IV insulin is interesting.
– What are current areas of uncertainty on this topic that can be potential areas for research?
This paper included only 156 patients from multiple studies. They also included pediatric patients. I think a large-scale, multi center study is warranted (and will likely be funded by a drug company like Lilly). If it showed compelling data and was used in the ADA guidelines, we could save a lot of $$ on ICU admissions. Granted, most of the $$$ comes from the ICU admission and other hospitals can do insulin gtts on the floor. It'd be interesting to see studies on outcome & cost/benefit with insulin gtts on floor vs. ICU setting.
Vincent review article
– How has reading this article changed your practice?
I don’t think my actual practice will change immediately as a result of this article, but I was interested to learn about the (limited) studies which demonstrated effectiveness and safety in the use of SC insulin instead of insulin infusion. I think this is an encouraging start to the possibility of practice being changed, but the power of these studies quoted in the paper is very limited.
– What information had you believed that was debunked after reading this?
I hadn’t previously questioned the use of SC insulin in the management of DKA, I just assumed it was always necessary to use an infusion. So this information was eye opening for me, and seems promising for potential future use of SC injections in an IMCU setting instead of needing an ICU level of care.
– What current areas of uncertainty on this topic that can be potential areas of ressearch.
As I mentioned above, this review highlights some promising findings, but future research needs to be done with better powered studies.
The McPhee article (use of Etomidate) is a retrospective cohort study with a large number of patients (strength). Its greatest limitation is the lack of generalizability of data as the patients included were only those intubated while in the ICU (none intubated in ED). So in terms of the utility of the findings to us as ED physicians, this is limited. The main outcome of the study is that single dose etomidate administration in critically ill patients was not associated with higher mortality or other adverse outcomes. Based on this study and lack of evidence that etomidate is associated with increased mortality, then I feel it’s reasonable to continue use of etomidate for intubation.
Vincent Review Article
How has reading the article changed your practice?
– Interesting to know about potential areas for cost savings. Think this would be more applicable if I had interest in global health. At BMC, until medicine service gets on board with this, don’t think it will change practice much.
What information had you believed in previously that were debunked by reading this article?
– thought that IV hydration would be a must for even those with mild DKA. This article seems to suggest that PO hydration and frequent s.c. insulin could do the trick in a non-critically ill person.
What new information did you learn from reading this article?
– Certain European centers allow insulin infusion outside of the ED or ICU
What are current areas of uncertainty on this topic that can be potential areas for research?
– Seems that most cost savings come from being outside of the ICU since lispro more expensive than regular insulin and each patient ended up getting about the same number of units. Would be good to see study on whether there are really that many adverse effects for pts being treated with insulin infusion on the floor. If we can mitigate concerns of hypoglycemia or hypokalemia with appropriate floor protocols, this could be source of large cost savings for the hospital.
1 – How has reading the article changed your practice?
I don’t think it will change my practice too much. I can imagine a specific scenario where a patient just barely meets criteria for DKA (e.g. BG 260, HCO3 15, pH 7.3, 1+ ketones, etc) who I would consider using a SQ insulin regimen to save a MICU bed, but for everyone else, I feel like I would still put in the MICU. We know that the mortality from DKA nowadays is mostly iatrogenic – i.e. from hypokalemia in the setting of insulin treatment. The MICU bed in my mind is less about the insulin drip than about the level of nursing care for frequent lab draws to check for K, HCo3, closing of anion gap, and glucose level. If someone is getting q1h SC insulin (and the mean time for resolution of the DKA is still 10 hours), they for sure should be getting some frequent K checks. If that can be accomplished on the floor, then I’m all for it.
2) What information had you believed in previously that were debunked by reading this article?
I didn’t realize the half life of IV insulin is only 10 minutes.
3) What new information did you learn from reading this article?
I learned that some European sites are able to use insulin drips on the floors
4) What are current areas of uncertainty on this topic that can be potential areas for research?
This paper has made me think of whether another strategy using both IV and SQ insulin might reduce length of stay – e.g. potentially starting with an IV bolus of regular insulin, and giving SQ lispro at the same time? If IV insulin has a half life of 10-20 min and SQ lispro starts acting within 20 minutes, it might be a way to speed up the process of resolving DKA without resorting to an insulin drip.
Vincent article:
– How has reading the article changed your practice?
This article encourages our sometimes practice of trying to fix some of the milder dka patients down in the ed so we can send them to the floor (not in dka but for hyperglycemia/management of whatever else they have going on/dm teaching/regimen overhaul etc) and brings up possibilities for changing the admission level of others who remain in dka after initial management.
– what information had you believed in previously that were debunked by reading this article?
It was easy to believe that insulin gtt was th4 only reasonable way to treat dka, even in the milder cases where the patient looks so good and it feels like overkill, so it was refreshing to see that ther4 are places exploring/using other protocols. I do, however, take Wilbur’s point about the frequent lite checks being integral to the management of dka and the reminder that ensuring vigilance in that area can’t be left out as we, and this article, focus on the insulin/glucose part.
– What new information did you learn from reading this article? We all knew that you 2ere supposed t start your subQ insulin several hours before turning off your drip because its onset is so much slower than the gtt’s offset but I, too, was shocked by how short that really is. 9min is wicked short!!
– What are current areas of uncertainty on this topic that can be potential areas for research?
I’d certainly Like to see a large randomized study on this topic given the relatively small number in this review. It seems like a very reasonable treatment option, and I often feel a bit silly putting someone with a pH of of 7.28, a bicarb of 14, and a small gap into the ICU, but we would need a nice solid bit of research to convince some of our medicine colleagues to take those patients elsewhere.
McPhee article:
-This one is a retrospective cohort study, its methods seem sound, its groups were quite similar despite obviously not being randomized, and it was highly powered given its large# of patients; all of these are strengths.
-I don’t know about limitations in the study itself but a huge limitation is how applicable it is to us in the ED. these patients were incubated 4 hours or more into their stay, which makes me wonder if they were not super sick in the ED, or if they had infections that weren’t responding to standard sepsis coverage (more sick?) or if they were preferentially patients who were volume overloaded 2/2 sepsis management protocols. In any of these cases they don’t represent our whole cohort of sepsis patients.
-because of this huge limitation for us its utility is quite limited, it’s food forethought but not much more.
-the outcome is pretty clear – that single dose etomidate in initially non-intubated ICU patients admitted for sepsis does not increase adverse outcomes including mortality
-I don’t think this changes our practice because it was too far removed from our patient population (of course if it was applicable to our patients it would mean no change in practice) but we will have to wait for a different study if we want data on whether we should change our Intubation etomidate use in septic patients.
How has reading the article changed your practice?
Regardless that the increase in mortality is statistically insignificant, I think this makes me think twice about using Etomidate in septic patients. We know that it suppresses the adrenal glands (RR of 1.3 in this review). If there are equivalent agents with similar HD profiles…why not use them –> looking at you ketamine.
What information had you believed in previously that were debunked by reading this article?
I did not know the data for increased mortality and etomidate was so flawed and largely taken from a secondary data set (CORTICUS study).
What new information did you learn from reading this article?
Only two studies have looked at Etomidate head-to-head against other sedative agents.
What are current areas of uncertainty on this topic that can be potential areas for research?
In similar patients with similar illness severity, does Ketamine use improve mortality over Etomidate?
Not much, its nice to know alternate pathways exist but the n on these studies is low and for me they didnt show statistical benefit on the things that really mattered over what is currently considered to be standard of care
– What information had you believed in previously that were debunked by reading this article?
that not all DKA needs an insulin gtt and that mild/moderate can be managed with subQ insulin
– What new information did you learn from reading this article?
something that i have looked at in the ed (and stated above) is how mild/moderate DKA can be managed without a insulin gtt. this article shows potential ways of actually managing that (instead of just winging it) which I think is useful
– What are current areas of uncertainty on this topic that can be potential areas for research?
need larger studies and obviously more studies done in the US before this can bring forward a real change. the cost savings aspect is good for developing countries but unless there is significant data that shows that subQ insulin works as well it will be hard to change the mindset of what is already set as recommended care
McPhee
What are some strengths of the study?
Good retrospective study. Looks at good question. Large study. Randomized. Looked at sick and pertinent patients
What are the limitations?
It is retrospective so that limits it. Also not sure why they didn’t use patients outside of the ICU. Perhaps those are sicker one can argue?
What are the main outcomes of the study?
It found what it was trying to argue – that single dose of etomidate is not associated with higher mortality. Also found that it doesn’t increase LoS and pressors/ventilation in patients. using this data it is arguing that there is no significant adrenal suppression that occurs when patients get one dose of etomidate for intubation
Does reading this article change your practice? If so, how?
Found this to be very interesting. i was not aware that this was such a hot topic. I will definitely change my practice should further data goes against this study but at this point I am not convinced that single dose etomidate increases mortality (so i agree with this study for now)
McPhee
Number of patients in study and methodology are this paper’s strengths. I also liked how they tried to control for physiology by only including ICU patients as these have the best documentation before and after intubation. I also liked how they addressed the two most referenced studies for why many people associate this drug with mortality for sick patients.
This also leads to limitations as there weren’t any patients with intubations in the ED in this study which limits its usefulness for ED providers. This paper is also retrospective.
Primary outcome was explicitly outlines as mortality associated with etomidate dose for intubation. In combination with other outcomes like LOS, pressor requirement, etc.
I don’t think this will change my practice as there seems a need for more data needed before a consensus will be reached about this drug but I consider etomidate acceptable (especially with no difference in mortality from this study) but will defer to ketamine for patients that I worry about adrenal suppression (which was also demonstrated in this paper)
Vincent
I don’t think this paper will change my practice as I also routinely place an IV for these patients due to the need for closer monitoring and redraw of bloods. The medicine service has been amenable for SC insulin for DKA patiens who aren’t particularly sick in the past so I don’t see much resistance if this practice changes but I don’t think they would be comfortable with no IV or IVFs for these patients. This paper does not have strong enough data to support a change for me- especially when the risk of serious metabolic derangements are possible and I would rather have IV access and give medicaitons and fluids via this route since I already have access
I did not know the differences in onset and half-life with various routes of insulin administration.
It was useful to see/learn a designed theoretical protocol for SC administration of insulin for DKA; it is interesting as a theoretical regimen for patients to require a lower level of care if this regimen is shown to be effective but the number of patients is just too low to be of any use for me to change my practice.
I think in an era of cost effective car,e there definitely is more room for studies to determine if there are any complications associated with this approach to DKA; I can see it reasonable to avoid an ICU admission, especially for “milder” DKA patients. Again the number for this study is just too low to really have an impact on changing the standard of care, or giving providersthe confidence to do the SC insulin only regimen this paper proposes.
16 comments
Vincent article: Treatment of DKA with sq lispro
– How has reading the article changed your practice?
This article has not completely changed my practice, but I would like to look further into whether some of our more straight-forward DKA patients could potentially be placed in step down with q2h lispro injections, especially when we are short on critical care beds.
– What information had you believed in previously that were debunked by reading this article?
I previously believed that DKA patients needed to be on insulin drips because that was the only easily titratable regimen. This article would argue, however, that lispro can be just as easily started and stopped accordingly.
– What new information did you learn from reading this article?
I learned the fast onset of action and the short duration of action of lispro that would make it a possible candidate as a replacement for a regular insulin drip. In comparison, I did not realize how long it took for an injection of regular insulin to reach its effect.
– What are current areas of uncertainty on this topic that can be potential areas for research?
One thing I found interesting was that this study was sponsored by Eli Lilly, who makes lispro and regular insulin. They mention at one point that lispro is more expensive than regular insulin and argue that overall costs would be lowered if the patient did not have to be in the ICU, but I wonder whether they would still end up profiting if this change was made widespread. Maybe I’m just cynical and paranoid, but possible ulterior motives are at least something to be aware of.
Good catch on the potential conflict of interest. Gives less credence to the cost-saving argument.
You’re spot on Ellie.
I also have a concern that the SC insulin review by Vincent et al included mostly smaller randomized studies (only 156 in all). Perhaps the power of these studies even combined may not be able to detect small differences in complication rates compared to standard insulin drip.
But certainly I think it’s completely reasonable to put people in stepdown with mild or moderate DKA on SC insulin at this time. Like Andy Ulrich says, “there’s a hospital attached to our emergency department”!
As for the Mcphee Etomidate article, the methodology is pretty strong especially for a retrospective article. It’s good example of being able to glean a lot of useful information and reach some level of conclusion with a large study database if randomized controlled trials are difficult.
However, my beef is that it included only ICU intubations. My concern is that perhaps their entire patient population weren’t sick enough to need intubation in the ED? Or perhaps the patients aren’t the same as the ones we’re treating.
It is interesting that their etomidate group was even sicker and did just as well.
Nevertheless, the literature goes back and forth on this and in my opinion, it is currently just as acceptable to use etomidate as it is to choose a different agent.
Considering alternatives such as ketamine that does not blunt the blood pressure, it is certainly reasonable to use it for now until further research puts this to rest.
How has reading the article changed your practice?
At Lahey, the other day I had a 21 y/o gentleman, new-onset diabetes dx in mild DKA. I discussed with Brandon Libby (former BMC resident) this article and managing the patient with sq insulin. We tried it for a bit until Endocrinology recommended insulin gtt. I think it’s a perfectly reasonable strategy for the “softer” DKA patients (i.e. ones you’d put on the floor)
– What information had you believed in previously that were debunked by reading this article?
I had no idea there was “mild” DKA. I thought if you had DKA, it was severe. I thought IV insulin lasted a lot longer than “a half life of9 minutes”
– What new information did you learn from reading this article?
I had no idea that DKA could be managed with sq insulin prior to getting the patient’s glucose <250. The fact that there are multiple papers showing similar effect to IV insulin is interesting.
– What are current areas of uncertainty on this topic that can be potential areas for research?
This paper included only 156 patients from multiple studies. They also included pediatric patients. I think a large-scale, multi center study is warranted (and will likely be funded by a drug company like Lilly). If it showed compelling data and was used in the ADA guidelines, we could save a lot of $$ on ICU admissions. Granted, most of the $$$ comes from the ICU admission and other hospitals can do insulin gtts on the floor. It'd be interesting to see studies on outcome & cost/benefit with insulin gtts on floor vs. ICU setting.
Vincent review article
– How has reading this article changed your practice?
I don’t think my actual practice will change immediately as a result of this article, but I was interested to learn about the (limited) studies which demonstrated effectiveness and safety in the use of SC insulin instead of insulin infusion. I think this is an encouraging start to the possibility of practice being changed, but the power of these studies quoted in the paper is very limited.
– What information had you believed that was debunked after reading this?
I hadn’t previously questioned the use of SC insulin in the management of DKA, I just assumed it was always necessary to use an infusion. So this information was eye opening for me, and seems promising for potential future use of SC injections in an IMCU setting instead of needing an ICU level of care.
– What current areas of uncertainty on this topic that can be potential areas of ressearch.
As I mentioned above, this review highlights some promising findings, but future research needs to be done with better powered studies.
The McPhee article (use of Etomidate) is a retrospective cohort study with a large number of patients (strength). Its greatest limitation is the lack of generalizability of data as the patients included were only those intubated while in the ICU (none intubated in ED). So in terms of the utility of the findings to us as ED physicians, this is limited. The main outcome of the study is that single dose etomidate administration in critically ill patients was not associated with higher mortality or other adverse outcomes. Based on this study and lack of evidence that etomidate is associated with increased mortality, then I feel it’s reasonable to continue use of etomidate for intubation.
Vincent Review Article
How has reading the article changed your practice?
– Interesting to know about potential areas for cost savings. Think this would be more applicable if I had interest in global health. At BMC, until medicine service gets on board with this, don’t think it will change practice much.
What information had you believed in previously that were debunked by reading this article?
– thought that IV hydration would be a must for even those with mild DKA. This article seems to suggest that PO hydration and frequent s.c. insulin could do the trick in a non-critically ill person.
What new information did you learn from reading this article?
– Certain European centers allow insulin infusion outside of the ED or ICU
What are current areas of uncertainty on this topic that can be potential areas for research?
– Seems that most cost savings come from being outside of the ICU since lispro more expensive than regular insulin and each patient ended up getting about the same number of units. Would be good to see study on whether there are really that many adverse effects for pts being treated with insulin infusion on the floor. If we can mitigate concerns of hypoglycemia or hypokalemia with appropriate floor protocols, this could be source of large cost savings for the hospital.
SC Insulin for Mild DKA
1 – How has reading the article changed your practice?
I don’t think it will change my practice too much. I can imagine a specific scenario where a patient just barely meets criteria for DKA (e.g. BG 260, HCO3 15, pH 7.3, 1+ ketones, etc) who I would consider using a SQ insulin regimen to save a MICU bed, but for everyone else, I feel like I would still put in the MICU. We know that the mortality from DKA nowadays is mostly iatrogenic – i.e. from hypokalemia in the setting of insulin treatment. The MICU bed in my mind is less about the insulin drip than about the level of nursing care for frequent lab draws to check for K, HCo3, closing of anion gap, and glucose level. If someone is getting q1h SC insulin (and the mean time for resolution of the DKA is still 10 hours), they for sure should be getting some frequent K checks. If that can be accomplished on the floor, then I’m all for it.
2) What information had you believed in previously that were debunked by reading this article?
I didn’t realize the half life of IV insulin is only 10 minutes.
3) What new information did you learn from reading this article?
I learned that some European sites are able to use insulin drips on the floors
4) What are current areas of uncertainty on this topic that can be potential areas for research?
This paper has made me think of whether another strategy using both IV and SQ insulin might reduce length of stay – e.g. potentially starting with an IV bolus of regular insulin, and giving SQ lispro at the same time? If IV insulin has a half life of 10-20 min and SQ lispro starts acting within 20 minutes, it might be a way to speed up the process of resolving DKA without resorting to an insulin drip.
Vincent article:
– How has reading the article changed your practice?
This article encourages our sometimes practice of trying to fix some of the milder dka patients down in the ed so we can send them to the floor (not in dka but for hyperglycemia/management of whatever else they have going on/dm teaching/regimen overhaul etc) and brings up possibilities for changing the admission level of others who remain in dka after initial management.
– what information had you believed in previously that were debunked by reading this article?
It was easy to believe that insulin gtt was th4 only reasonable way to treat dka, even in the milder cases where the patient looks so good and it feels like overkill, so it was refreshing to see that ther4 are places exploring/using other protocols. I do, however, take Wilbur’s point about the frequent lite checks being integral to the management of dka and the reminder that ensuring vigilance in that area can’t be left out as we, and this article, focus on the insulin/glucose part.
– What new information did you learn from reading this article? We all knew that you 2ere supposed t start your subQ insulin several hours before turning off your drip because its onset is so much slower than the gtt’s offset but I, too, was shocked by how short that really is. 9min is wicked short!!
– What are current areas of uncertainty on this topic that can be potential areas for research?
I’d certainly Like to see a large randomized study on this topic given the relatively small number in this review. It seems like a very reasonable treatment option, and I often feel a bit silly putting someone with a pH of of 7.28, a bicarb of 14, and a small gap into the ICU, but we would need a nice solid bit of research to convince some of our medicine colleagues to take those patients elsewhere.
McPhee article:
-This one is a retrospective cohort study, its methods seem sound, its groups were quite similar despite obviously not being randomized, and it was highly powered given its large# of patients; all of these are strengths.
-I don’t know about limitations in the study itself but a huge limitation is how applicable it is to us in the ED. these patients were incubated 4 hours or more into their stay, which makes me wonder if they were not super sick in the ED, or if they had infections that weren’t responding to standard sepsis coverage (more sick?) or if they were preferentially patients who were volume overloaded 2/2 sepsis management protocols. In any of these cases they don’t represent our whole cohort of sepsis patients.
-because of this huge limitation for us its utility is quite limited, it’s food forethought but not much more.
-the outcome is pretty clear – that single dose etomidate in initially non-intubated ICU patients admitted for sepsis does not increase adverse outcomes including mortality
-I don’t think this changes our practice because it was too far removed from our patient population (of course if it was applicable to our patients it would mean no change in practice) but we will have to wait for a different study if we want data on whether we should change our Intubation etomidate use in septic patients.
How has reading the article changed your practice?
Regardless that the increase in mortality is statistically insignificant, I think this makes me think twice about using Etomidate in septic patients. We know that it suppresses the adrenal glands (RR of 1.3 in this review). If there are equivalent agents with similar HD profiles…why not use them –> looking at you ketamine.
What information had you believed in previously that were debunked by reading this article?
I did not know the data for increased mortality and etomidate was so flawed and largely taken from a secondary data set (CORTICUS study).
What new information did you learn from reading this article?
Only two studies have looked at Etomidate head-to-head against other sedative agents.
What are current areas of uncertainty on this topic that can be potential areas for research?
In similar patients with similar illness severity, does Ketamine use improve mortality over Etomidate?
Not much, its nice to know alternate pathways exist but the n on these studies is low and for me they didnt show statistical benefit on the things that really mattered over what is currently considered to be standard of care
– What information had you believed in previously that were debunked by reading this article?
that not all DKA needs an insulin gtt and that mild/moderate can be managed with subQ insulin
– What new information did you learn from reading this article?
something that i have looked at in the ed (and stated above) is how mild/moderate DKA can be managed without a insulin gtt. this article shows potential ways of actually managing that (instead of just winging it) which I think is useful
– What are current areas of uncertainty on this topic that can be potential areas for research?
need larger studies and obviously more studies done in the US before this can bring forward a real change. the cost savings aspect is good for developing countries but unless there is significant data that shows that subQ insulin works as well it will be hard to change the mindset of what is already set as recommended care
McPhee
What are some strengths of the study?
Good retrospective study. Looks at good question. Large study. Randomized. Looked at sick and pertinent patients
What are the limitations?
It is retrospective so that limits it. Also not sure why they didn’t use patients outside of the ICU. Perhaps those are sicker one can argue?
What are the main outcomes of the study?
It found what it was trying to argue – that single dose of etomidate is not associated with higher mortality. Also found that it doesn’t increase LoS and pressors/ventilation in patients. using this data it is arguing that there is no significant adrenal suppression that occurs when patients get one dose of etomidate for intubation
Does reading this article change your practice? If so, how?
Found this to be very interesting. i was not aware that this was such a hot topic. I will definitely change my practice should further data goes against this study but at this point I am not convinced that single dose etomidate increases mortality (so i agree with this study for now)
McPhee
Number of patients in study and methodology are this paper’s strengths. I also liked how they tried to control for physiology by only including ICU patients as these have the best documentation before and after intubation. I also liked how they addressed the two most referenced studies for why many people associate this drug with mortality for sick patients.
This also leads to limitations as there weren’t any patients with intubations in the ED in this study which limits its usefulness for ED providers. This paper is also retrospective.
Primary outcome was explicitly outlines as mortality associated with etomidate dose for intubation. In combination with other outcomes like LOS, pressor requirement, etc.
I don’t think this will change my practice as there seems a need for more data needed before a consensus will be reached about this drug but I consider etomidate acceptable (especially with no difference in mortality from this study) but will defer to ketamine for patients that I worry about adrenal suppression (which was also demonstrated in this paper)
Vincent
I don’t think this paper will change my practice as I also routinely place an IV for these patients due to the need for closer monitoring and redraw of bloods. The medicine service has been amenable for SC insulin for DKA patiens who aren’t particularly sick in the past so I don’t see much resistance if this practice changes but I don’t think they would be comfortable with no IV or IVFs for these patients. This paper does not have strong enough data to support a change for me- especially when the risk of serious metabolic derangements are possible and I would rather have IV access and give medicaitons and fluids via this route since I already have access
I did not know the differences in onset and half-life with various routes of insulin administration.
It was useful to see/learn a designed theoretical protocol for SC administration of insulin for DKA; it is interesting as a theoretical regimen for patients to require a lower level of care if this regimen is shown to be effective but the number of patients is just too low to be of any use for me to change my practice.
I think in an era of cost effective car,e there definitely is more room for studies to determine if there are any complications associated with this approach to DKA; I can see it reasonable to avoid an ICU admission, especially for “milder” DKA patients. Again the number for this study is just too low to really have an impact on changing the standard of care, or giving providersthe confidence to do the SC insulin only regimen this paper proposes.