Utility of Initial Bolus Insulin in the Treatment of Diabetic Ketoacidosis

Goyal, Nikhil; Miller, Joseph; Sankey, Steadman S.; Mossallam, Usamah

doi:10.1016/j.jemermed.2007.11.033

Cited by 45 publications

(42 citation statements)

References 23 publications

(20 reference statements)

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“…We doubt this contributed to excessive hypoglycaemia in our fixed‐rate cohort. An initial insulin bolus has not previously been associated with increased hypoglycaemia, and our 24‐h hypoglycaemia incidence of 32.5% was actually lower than the 40% reported in the British study sharing our hypoglycaemia definition . Also, though we provided an identical dextrose infusion rate as in British guidelines, we did so in a 5% solution, whereas British guidelines use a 10% solution at 125 ml/h.…”

Section: Discussionsupporting

confidence: 87%

Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study

Lorenson

Cusumano

Stewart

et al. 2019

International Journal of Pharmacy Practice

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Objective To assess whether hypoglycaemia incidence during management of adult diabetic ketoacidosis (DKA) differed following transition from a fixed‐rate insulin protocol to a protocol using an empiric insulin rate reduction after normoglycaemia. Methods We retrospectively reviewed charts from adult patients managed with a DKA order set before and after order set revision. In cohort 1 (n = 77), insulin rate was 0.1 unit/kg/h with no adjustments and dextrose was infused at 12.5 g/h after glucose reached 250 mg/dl. In cohort 2 (n = 78), insulin was reduced to 0.05 unit/kg/h concurrent with dextrose initiation at 12.5 g/h after glucose reached 200 mg/dl. The primary outcome was hypoglycaemia (glucose < 70 mg/dl) within 24 h of the first order for insulin. Key findings The 24‐h incidence of hypoglycaemia was 19.2% in cohort 2 versus 32.5% in cohort 1; the adjusted odds ratio was 0.46 (95% confidence interval (CI) [0.21, 0.98]; P = 0.047). The 24‐h use of dextrose 50% in water (D50W) was also reduced in cohort 2. No differences were seen in anion gap or bicarbonate normalization, rebound hyperglycaemia or ICU length of stay. In most patients who became hypoglycaemic, the preceding glucose value was below 100 mg/dl. Conclusions The insulin rate‐reduction protocol was associated with less hypoglycaemia and no obvious disadvantage. Robust intervention for low‐normal glucose values could plausibly achieve low hypoglycaemia rates with either approach.

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Section: Discussionsupporting

confidence: 87%

Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study

Lorenson

Cusumano

Stewart

et al. 2019

International Journal of Pharmacy Practice

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“…In contrast, a prospective observational cohort study in 2007 ( n = 157) found no statistical difference in the incidence of hypoglycaemia, rate of glucose reduction, or length of hospital stay (63) and concluded that an initial bolus of intravenous insulin offered no significant clinical benefit or harm. The study was limited by lack of randomisation; standardised treatment protocols and used administration of 50% dextrose as a surrogate definition for hypoglycemia rather than serum glucose levels.…”

Section: Resultsmentioning

confidence: 98%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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BackgroundDiabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs).ObjectiveTo review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes.MethodsOvid Medline searches were conducted with limits “all adult” and published between “1973 to current” applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers’ assessment of title, abstract, and availability.ResultsA total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over “sliding scale” insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1–2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes.ConclusionThere are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.

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“…[1] It is also known that an initial IV insulin bolus may not be needed in the management of DKA if insulin therapy is started promptly at a dose of 0.14 IU/kg/h. [2,3] There are several ways to administer insulin therapy, which have been evaluated: continuous IV infusion (CII) or bolus IV, subcutaneous (SC) or intramuscular (IM) insulin therapy. It is generally accepted that CII of insulin is the preferred method of treating DKA; this has been incorporated into treatment protocols worldwide.…”

Section: Researchmentioning

confidence: 99%