Management of Critically Ill Persons with COVID-19 and Diabetes

COVID-19 disease poses a significant risk for critical illness, including hyperglycemic emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), especially in patients with diabetes. While treatment with a continuous insulin infusion is traditionally considered to be the standard of care in DKA management, subcutaneous insulin protocols have been utilized during the pandemic for treating mild-to moderate DKA with the goal of reducing personal protective equipment use, intensive care unit bed utilization, and health-care worker exposure to and transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Subcutaneous insulin protocols for DKA generally use an initial basal insulin dose with rapid-acting insulin administered every 3–4 h. Due to the risk for acute respiratory distress syndrome and acute renal injury in COVID-19 disease, judicious fluid and electrolyte management is indicated. To help further reduce the need for potential viral exposure, early data suggests the clinical efficacy and safety of continuous glucose monitoring (CGM) in the management of critically ill patients with COVID-19 disease.