Continuous intravenous infusion of small doses of insulin in treatment of diabetic ketoacidosis

Continuous intravenous infusion of small amounts of insulin has been used in the management of a series of patients with diabetic ketoacidosis. In 13 patients with a plasma glucose level on admission of 725 mg/100 ml (+/- 80 S.E. of mean) and an arterial pH of 7.07 +/- 0.05 a mean loading dose of 6.5 +/- 0.82 units of soluble insulin was administered intravenously, and thereafter a sustaining infusion of 6.5 +/- 0.82 U/hr was continued until ketosis was corrected and the plasma glucose fell below 300 mg/100 ml. The total insulin dose needed to achieve this was 39.2 +/- 6.6 units given over a 3 to 10-hour period. Plasma insulin was measured in patients who had not previously received insulin and the mean level at an infusion rate of 4 U/hr was 75.6 +/- 8.0 muU/ml. Plasma glucose fell at a regular rate of 101 +/- 11 mg/100 ml/hr, and ketosis improved in parallel. Plasma potassium was well maintained throughout treatment. This regimen of treatment was clinically effective and simple to follow.

Cerebral edema and depression of sensorium in nonketotic hyperosmolar coma

The influence of body water and solute equilibria between extracellular fluid and cerebrospinal fluid (CSF), both before and during therapy, was studied in fifty-three patients who had hyper-glycemia (blood glucose 600 mg./100 ml.) in the absence of ketoacidosis. Particular attention was directed to both depression of sensorium and the possible production of cerebral edema. Before therapy, depression of sensorium was highly correlated with plasma osmolality (r =.84), but not with glucose concentration or pH of either CSF or plasma. Plasma and CSF were in osmotic equilibrium before therapy (389 mOsm/kg.) but glucose concentration was significantly higher in plasma while Na+ and Cl− were higher in CSF. During treatment with insulin and hypotonic NaCl infusion, the osmolalities of CSF and plasma fell at essentially identical rates. Plasma osmolality fell as a consequence of both a fall in glucose concentration and a gain in free water, but the fall in CSF osmolality was almost entirely due to a gain in water by the CSF. Insulin administration was stopped when plasma glucose was about 250 mg./100 ml., and in all patients there was no increase in CSF pressure or clinical evidence of cerebral edema.

In patients with nonketotic coma, depression of sensorium is highly correlated with the plasma osmolality. During therapy with insulin and hypotonic NaCl infusion, it appears that cerebral edema does not occur if insulin is stopped before plasma glucose falls below 250 mg./100 ml.

Repetitive health examinations as an intervention measure

A cohort of 107 men aged 51-53 years with borderline levels of blood pressure, serum cholesterol, or glucose tolerance was recruited from a general population in central Zagreb, Yugoslavia, and randomized into two groups; one was treated with drugs and the other observed in a similar fashion but not treated. Ninety-five men appeared regularly for the check-ups over a 2-year period. Levels of systolic blood pressure, cholesterol, and glucose showed a substantial decrease over a period of 2 years in both treated and control groups. The possible effect of repeated check-ups and their implications are discussed.

Successful use of oral diazoxide in the treatment of severe toxaemia of pregnancy

Treatment with oral diazoxide for periods of 4 to 10 weeks in hospital allowed adequate control of hypertension with continuation of fetal growth in four patients with severe toxaemia. Two were insulin-dependent diabetics and one of these suffered from renal failure. In all patients albuminuria diminished markedly, while the fluid retention was controlled with frusemide. Three pregnancies were successfully terminated by lower segment caesarean section and in the remaining case vaginal delivery resulted in the birth of a healthy baby. Control of blood sugars presented no problems in the diabetic patients. Only minimal adjustments of insulin dosage were required. One of the non-diabetic patients developed mild hyperglycaemia which responded to tolbutamide. The babies, ranging in age from 5 to 12 months, have continued to thrive.

Use of diazoxide in hypertension with renal failure

Treatment with intravenous and oral diazoxide was given to a group of 39 patients suffering from severe drug-resistant hypertension associated with renal impairment. Rapid initial and good long-term control of hypertension was achieved in all cases without the production of clinically significant postural hypotension. The side effects of diazoxide, including its diabetogenic effect, were easily controlled. There was a highly significant improvement in renal function in most patients on long-term oral diazoxide therapy.Diazoxide may have an important place in both the short- and long-term therapy of resistant hypertension, particularly in association with renal damage.