Most of the guidelines modified the DKA management protocol to effectively treat serious hyperglycemia and in mean time reducing the risk of exposure of health staff and this especially critical as there is shortage of protective equipment and nursing staff in Libya. The corner of this modification was the use of the Subcutaneous approach rather than intravenous one in patient who are not severely acidotic (pH > 7, HCO₃ > 10) and non-pregnant female. Also, the use of insulin analogue, the long acting once daily and rapid acting every 3 hours by most of the published guidelines especially in conscious patient with mild to moderate DKA who can inject himself and even can check his finger stick blood sugar (FS) by use of reliable glucometer was of paramount in managing DKA while reducing the burden on heath staff. This approach actually not new as many studies proved that this approach was effective and safe previously in non-COVID 19 Mild to moderate uncomplicated DKA patients [12] [13] [14] [15] [16]. Studies show that use of lower fluid rate in COVID-19 patient admitted with DKA is important compared to the rate used for non-COVID-19 patients even in patient on steroids they usually increase the insulin doses by 50% rather than fluid rate. Patients with ESRD (End stage renal disease) need lower doses of insulin by nearly half [9] [10].

Many modified DKA approach was published recently. We try to put an algorithm derived from all these published protocols which is easy to apply in Libyan health care systems.

Generally, the target is to keep the blood sugar in range of 140 - 180 mg/dl with minimal or no hypoglycemia [5] [17]. The preferred way is by using SQ approach with basal and correction doses unless the patient is hemodynamically unstable, on TPN (total parenteral nutrition making his insulin doses unstable) where insulin infusion protocol is needed with blood glucose every one hour is mandatory [7].

When the patient becomes hemodynamically stable change the patient to basal-correction doses as soon as possible to limit the nurse contact. The initial dose of subcutaneous insulin administration at the time of transition can be determined as 60% - 80% of the insulin administered intravenously during the preceding 24 h. To avoid rebound hyperglycemia after transition, a sufficient duration of overlap with the insulin infusion and the subcutaneous insulin administration is required. Short-acting insulin can be administered 1 to 2 h and long-acting insulin 2 to 3 h prior to discontinuation of intravenous insulin administration [7].

Patients who are hemodynamically stable and not on high dose steroid at admission better to be managed with basal-correction doses or even basal-bolus, with correction doses with blood glucose monitored every 4 - 6 hours preferably by finger stick [7].

T1D (Type 1 diabetes).

T2D (Type 2 diabetes) on oral or insulin therapy.

Unknown with Admitted BG > 180 mg/dl.

In all these patients use basal-correction insulin doses and follow BG every 4 - 6 hrs.

Use basal-bolus plus correction doses and they should check BG before meals and at bed time.

Type 2 diabetics who was well controlled on diet control and there admitted BG < 180 can be managed in the first 24 hrs. With correction doses only to calculate their insulin requirements and then you can step up to adding basal insulin or basal bolus according to his oral intake.

How to calculate basal bolus regimen:

1) Patients who were on this regimen as outpatients and was with good glycemic control continue in hospital with same dose and adjust according to Finger stick sugar (FS).

2) Patients who are insulin naïve Total daily dose (TDD) calculated at 0.4/kg/day [7].

3) Patients with higher risk of hypoglycemia like patient with renal dysfunction, autonomic neuropathy, liver disease, cardiac disease. Elderly above >65 years, hypoglycemia unawareness their TDD should be calculated at 0.2/kg/day [7].

4) If human insulin is used the TDD should be divided into 4 portions (25% each), three before each meal of regular insulin and one basal NPH [19].

5) If analogues are used the TDD should be divided 50% basal analogues (Glargine 100 IU, Glargine 300 IU, detemir or Tresiba) and 50% of prandial insulin [19].

6) Prandial insulin analogues (Aspart, Lispro, Glulisine) which further divided into three doses equal before each meal.

How to calculate correction doses:

In patient who is NPO or not eating correction doses should be used in addition of basal insulin. Basal insulin is calculated as above. Correction doses calculated depending on blood glucose each 4 - 6 hrs using the following formula:

The patient blood glucose—120/Correction factor.

Correction factor is depending on the TDD. Correction factor indicates the decrease in blood glucose (mg/dl) expected with 1 unit of short acting insulin.

The correction dose is also required in patient who is eating to adjust for the Pre-meal blood glucose if more than 200 mg.

The following table shows the correction factor for each TDD insulin requirement per KG body weight [7] (Table 2).

Note: Patient who is in transition from Insulin infusion should be managed with either Basal, correction doses if he is not eating or basal, bolus with correction if he starts to eat [20].