Guidance on the management of Diabetic Ketoacidosis in the exceptional circumstances of the COVID-19 pandemic

During the early stages of the COVID-19 pandemic, hospitals in London, the UK epicentre, reported an unusually high number of people presenting with COVID-19 disease developing diabetic ketoacidosis, hyperosmolar hyperglycaemic state, or a combination of both. Very high doses of insulin were often needed to manage the hyperglycaemia. It has been proposed that these metabolic disturbances may result from severe insulin resistance combined with decreased insulin secretion due to beta cell dysfunction [1]. The increased demand for pumps to deliver inotropes has led to concerns of possible shortages of infusion pumps and/or 50 ml syringes being available for insulin infusions to manage these hyperglycaemic emergencies. Concerns were also raised about the potential risk of exacerbating ‘lung leak’ in COVID-19 positive patients using the traditional rates of fluid replacement for the management of DKA. Clinicians therefore requested that a subcutaneous insulin regimen be made available as a backup strategy for managing diabetic ketoacidosis and guidance on the fluid replacement regimen.