REBEL Core Cast – DKA: Beyond the Basics Part 1 – The SQuID Protocol

Oct 17, 2025

Explore the innovative SQuID Protocol for managing mild-to-moderate DKA using subcutaneous insulin instead of IV drips. Discover the impressive results: fewer ICU admissions and shorter ED stays, while nursing workloads remain unchanged. Delve into critical concepts like focusing on closing the anion gap over just normalizing blood sugar. Learn why pediatric approaches can inform adult practices, and how the two-bag system effectively manages insulin without risking hypoglycemia, offering a fresh perspective on DKA treatment.

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INSIGHT

SQuID Protocol Overview

The SQuID protocol uses subcutaneous lispro q4h plus a basal glargine at time zero to treat eligible mild–moderate DKA patients.
This approach aimed to shift care out of the ICU and shorten ED stays while maintaining safety.

ADVICE

Select Patients Carefully

Exclude severe DKA, pregnancy, altered mental status, ESRD, CHF, major infection, and surgical needs when selecting SQuID candidates.
Only apply SQuID to adults with mild–moderate DKA and no comorbidities that demand ICU care.

INSIGHT

Operational Gains With Similar Safety

In the study, SQuID reduced ED length of stay by about three hours and dramatically lowered ICU admissions.
Safety outcomes, including hypoglycemia, were similar to traditional insulin drips.

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🗝️ Key Points

🛏️ Fewer ICU Admissions
Only 5 patients in the SQuID group required ICU care vs 99 in the traditional insulin drip group.
⏱️ Shorter ED Stays
ED length of stay dropped by ~3 hours in the SQuID group—an operational win in crowded departments.
💉 No Drop in Nursing Workload
Despite using subQ insulin, nurses still performed hourly glucose checks and frequent injections.
🧪 Focus on the Anion Gap
DKA resolution = closing the anion gap, not just normalizing blood sugar—critical concept for trainees and nurses alike.
👶 Peds Has the Edge
Pediatric ICUs routinely use a 2-bag system (D10 + electrolytes vs electrolytes alone) to safely continue insulin while managing glucose—adult medicine should take note.

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📝 Introduction

In this episode of REBEL Cast, we dive into part one of our Diabetic Ketoacidosis (DKA) series with a twist—subcutaneous insulin instead of the traditional IV drip. We explore the SQuID Protocol (Subcutaneous Insulin in DKA), which could potentially shift how we manage mild to moderate DKA—from the ICU to the general floor.

With ICU bed shortages, ED boarding, and nursing resource challenges, it’s time to ask: Do all DKA patients really need a drip and an ICU bed?

We reviewed a quasi-experimental study comparing traditional insulin drips versus subcutaneous insulin (lispro q4h + glargine at time zero) in a busy urban ED. The results? Promising—but not without caveats.

🦑 SQuID Protocol

🚨 Clinical Bottom Line

The SQuID Protocol appears safe and effective for carefully selected patients with mild to moderate DKA. It may reduce ICU admissions and shorten ED stays. But implementation requires thoughtful coordination, nursing comfort, and institutional buy-in. This isn’t ready for prime time everywhere—but it’s worth knowing and considering when ICU resources are tight.

Post Peer Reviewed By: Marco Propersi (Twitter/X: @Marco_propersi), and Kim Bambach, MD

Show Notes By: Mark Ramzy, DO

Authors

Mark Ramzy, DO

Co-Editor-in-Chief

RWJBH / Rutgers Health, Newark, NJ

Frank Lodeserto

Associate Editor

Cape Fear Valley Medical Center, Fayetteville NC

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