Continuous low-dose infusion of insulin in the treatment of diabetic ketoacidosis in children

Martin, Malcolm M.; Martin, Arline L.A.

doi:10.1016/s0022-3476(76)80386-1

Cited by 47 publications

(20 citation statements)

References 22 publications

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“… The dose of insulin should usually remain at 0.1 unit/kg/h at least until resolution of DKA (pH > 7.30, bicarbonate > 15 mmol/L and/or closure of the anion gap), which invariably takes longer than normalization of blood glucose concentrations (B) (68). If the patient demonstrates marked sensitivity to insulin (e.g., some young children with DKA, patients with HHS, and some older children with established diabetes), the dose may be decreased to 0.05 unit/kg/h, or less, provided that metabolic acidosis continues to resolve. During initial volume expansion the plasma glucose concentration falls steeply (61) (C). Thereafter, and after commencing insulin therapy, the plasma glucose concentration typically decreases at a rate of 2–5 mmol/L/h, depending on the timing and amount of glucose administration (C) (69–75). To prevent an unduly rapid decrease in plasma glucose concentration and hypoglycemia, 5% glucose should be added to the IV fluid (e.g., 5% glucose in 0.45% saline) when the plasma glucose falls to approximately 14–17 mmol/L (250–300 mg/dL), or sooner if the rate of fall is precipitous (B). …”

Section: Management Of Dkamentioning

confidence: 99%

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Diabetic ketoacidosis

et al. 2007

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Section: Management Of Dkamentioning

confidence: 99%

“…During initial volume expansion the plasma glucose concentration falls steeply (61) (C). Thereafter, and after commencing insulin therapy, the plasma glucose concentration typically decreases at a rate of 2–5 mmol/L/h, depending on the timing and amount of glucose administration (C) (69–75).…”

Section: Management Of Dkamentioning

confidence: 99%

Diabetic ketoacidosis

et al. 2007

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“…Although there are limited data on which to base dosing recommendations, current therapy generally includes an initial bolus dose of 0.1 units/kg followed by a continuous infusion of 0.1 units/kg/h. 1,2 The goal of therapy is a gradual reduction of serum glucose in increments less than 100 mg/dL/h. These recommendations are based on the assumption that a more rapid reduction of serum glucose and thereby serum osmolarity may be one of the risk factors for the development of cerebral edema.…”

Section: Introductionmentioning

confidence: 99%

Serum Glucose Changes During Insulin Therapy in Pediatric Patients With Diabetic Ketoacidosis

Bradley¹,

Tobias

2007

American Journal of Therapeutics

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There are limited data on which to base insulin dosing schemes for diabetic ketoacidosis (DKA). The goal of therapy is to avoid excessive decreases in serum glucose (greater than 100 mg/dL/h) because of the risks of rapid changes in serum osmolarity and the potential risk of cerebral edema. We retrospectively reviewed the therapy of DKA in pediatric patients admitted to our Pediatric Intensive Care Unit over the past 10 years. There were 35 patients who received IV bolus insulin therapy (0.08 to 1.6 units/kg, 0.24 +/- 0.27 units/kg). The serum-glucose decrease was less than or equal to 100 mg/dL in 10 patients, 101 to 200 mg/dL in 13 patients, 201 to 300 mg/dL in 8 patients, 301 to 400 mg/dL in 2 patients, and more than 500 mg/dL in 2 patients. In patients who received 0.05 to 0.1 units/kg of insulin as a bolus dose, the decrease in serum glucose was greater than 100 mg/dL in 5 of 11 patients. An insulin infusion was administered to 91 patients. During the 243 hours of insulin infusion therapy, the decline in serum glucose was 0 to 100 mg/dL during 162 hours, 101 to 200 mg/dL during 49 hours, 201 to 300 mg/dL during 8 hours, and more than 300 mg/dL during 3 hours. Of the 193 hours of 0.05 to 0.1 units/kg/h insulin administration, there were 47 hours (24%) during which the serum-glucose decrease was greater than 100 mg/dL. Of the 21 hours of insulin administration at less than 0.05 units/kg/h, there was 1 hour (4.8%) where the serum-glucose decrease was greater than 100 mg/dL (P = 0.05 vs. insulin infusion at 0.05 to 0.1 units/kg/h). Commonly used insulin dosing regimens of a bolus of 0.1 units/kg followed by an infusion of 0.05 to 0.1 units/kg/h frequently resulted in a decrease in serum glucose of greater than 100 mg/dL/h. Prospective trials are needed to more accurately define appropriate insulin dosing regimens for pediatric patients with DKA.

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“…In insulin-naive untreated type-1 diabetic children with DKA, serum insulin concentrations are < 5 μU/ml (unpublished observation) and increase upon therapeutic intravenous insulin infusion at a rate of 0.1 U/kg/h to approximately 60 - 100 μU/ml [13,18-20]. Such serum insulin levels could also have been assumed in our patient at the time of developing brain oedema (unfortunately the insulin levels were not measured).…”

Section: Discussionmentioning

confidence: 99%

Symptomatic cerebral oedema during treatment of diabetic ketoacidosis: effect of adjuvant octreotide infusion

Seewi

Vierzig

Roth

et al. 2010

Diabetol Metab Syndr

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IntroductionA potentially lethal complication of diabetic ketoacidosis (DKA) in children is brain oedema, whether caused by DKA itself or by the therapeutic infusion of insulin and fluids.Case presentationA 10-year old previously healthy boy with DKA became unconscious and apnoeic due to cerebral oedema (confirmed by abnormal EEG and CT-scan) during treatment with intravenous fluids (36 ml/h) and insulin (0.1 units/kg/h). He was intubated and artificially ventilated, without impact on EEG and CT-scan. Subsequently, adjuvant infusion of octreotide was applied (3.5 μg/kg/h), suppressing growth hormone (GH) and IGF-1 production and necessitating the insulin dose to be reduced to 0.05 - 0.025 units/kg/h. The brain oedema improved and the boy made a full recovery.ConclusionCo-therapy with octreotide was associated with a favourable outcome in the present patient with DKA and cerebral oedema. Whether this could be ascribed to the effects of octreotide on the insulin requirement or on the GH/IGF-axis remains to be elucidated.

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Continuous low-dose infusion of insulin in the treatment of diabetic ketoacidosis in children

Cited by 47 publications

References 22 publications

Diabetic ketoacidosis

Diabetic ketoacidosis

Serum Glucose Changes During Insulin Therapy in Pediatric Patients With Diabetic Ketoacidosis

Symptomatic cerebral oedema during treatment of diabetic ketoacidosis: effect of adjuvant octreotide infusion

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