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Belal MM, Khalefa BB, Rabea EM, Aly Yassin MN, Bashir MN, Abd El-Hameed MM, Elkoumi O, Saad SM, Saad LM, Elkasaby MH. Low dose insulin infusion versus the standard dose in children with diabetic ketoacidosis: a meta-analysis. Future Sci OA 2024; 10:FSO956. [PMID: 38827803 PMCID: PMC11140676 DOI: 10.2144/fsoa-2023-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/13/2023] [Indexed: 06/05/2024] Open
Abstract
Aim: This systematic review aims to consolidate findings from current clinical trials that compare the effectiveness of insulin infusion at 0.05 IU/kg/h versus 0.1 IU/kg/h in managing pediatric diabetic ketoacidosis. Methods: We searched several databases, including PubMed, Embase, Scopus, Cochrane Central and Web of Science. Our primary outcomes were time to reach blood glucose ≤250 mg/dl and time to resolution of acidosis. Secondary outcomes included rate of blood glucose decrease per hour, incidence of hypoglycemia, hypokalemia, treatment failure, and cerebral edema. Results & conclusion: The present study establishes that a low insulin dose exhibits comparable efficacy to the standard dosage for managing pediatric patients suffering from diabetic ketoacidosis, with a lower incidence of complications.
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Affiliation(s)
- Mohamed Mohamed Belal
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Basma Badrawy Khalefa
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Ain shams University, Cairo, Egypt
| | - Eslam Mohammed Rabea
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mazen Negmeldin Aly Yassin
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed Nabih Bashir
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Malak Mohamed Abd El-Hameed
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Ash Sharqia, Egypt
| | - Omar Elkoumi
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Suez University, Suez, Egypt
| | - Saad Mohamed Saad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Loubna Mohamed Saad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mohamed Hamouda Elkasaby
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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Abstract
Diabetic ketoacidosis (DKA) is a common, serious acute complication in children with diabetes mellitus (DM). DKA can accompany new-onset type 1 insulin-dependent DM, or it can occur with established type 1 DM, during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. In addition, DKA episodes in children with type 2 DM are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a sizable proportion of patients with new-onset DM present with DKA. The purpose of this comprehensive review is to acquaint clinicians with details regarding the pathophysiology, treatment caveats, and potential complications of DKA.
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3
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Insulin Infusion Dosing in Pediatric Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor 2023; 5:e0857. [PMID: 36844374 PMCID: PMC9943979 DOI: 10.1097/cce.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
In children with diabetic ketoacidosis (DKA), insulin infusions are the mainstay of treatment; however, optimal dosing remains unclear. Our objective was to compare the efficacy and safety of different insulin infusion doses for the treatment of pediatric DKA. DATA SOURCES We searched MEDLINE, EMBASE, PubMed, and Cochrane from inception to April 1, 2022. STUDY SELECTION We included randomized controlled trials (RCTs) of children with DKA comparing intravenous insulin infusion administered at 0.05 units/kg/hr (low dose) versus 0.1 units/kg/hr (standard dose). DATA EXTRACTION We extracted data independently and in duplicate and pooled using a random effects model. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS We included four RCTs (n = 190 participants). In children with DKA, low-dose compared with standard-dose insulin infusion probably has no effect on time to resolution of hyperglycemia (mean difference [MD], 0.22 hr fewer; 95% CI, 1.19 hr fewer to 0.75 hr more; moderate certainty), or time to resolution of acidosis (MD, 0.61 hr more; 95% CI, 1.81 hr fewer to 3.02 hr more; moderate certainty). Low-dose insulin infusion probably decreases the incidence of hypokalemia (relative risk [RR], 0.65; 95% CI, 0.47-0.89; moderate certainty) and hypoglycemia (RR, 0.37; 95% CI, 0.15-0.80; moderate certainty), but may have no effect on rate of change of blood glucose (MD, 0.42 mmol/L/hr slower; 95% CI, 1 mmol/L/hr slower to 0.18 mmol/L/hr faster; low certainty). CONCLUSIONS In children with DKA, the use of low-dose insulin infusion is probably as efficacious as standard-dose insulin, and probably reduces treatment-related adverse events. Imprecision limited the certainty in the outcomes of interest, and the generalizability of the results is limited by all studies being performed in a single country.
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Mastromauro C, Polidori N, Blasetti A, Comegna L, Chiarelli F, Mohn A, Giannini C. Insulin resistance relates to DKA severity and affects insulin requirement in children with type 1 diabetes at onset. Pediatr Diabetes 2022; 23:1613-1620. [PMID: 36183171 PMCID: PMC10092633 DOI: 10.1111/pedi.13424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/09/2022] [Accepted: 09/27/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Fluid and insulin treatments are the cornerstones of DKA management and indications on dosages are available. However, according to possible confounding factors, relevant data are still required to explain the different insulin dosages adopted at diabetes onset, particularly based upon insulin sensitivity. OBJECTIVE We aimed to explore whether DKA severity is related to different insulin sensitivity states, thus resulting in different insulin requirement at diabetes onset. METHODS Retrospective data from hospital records of 62 newly diagnosed children with type 1 diabetes with DKA were analyzed. The population was divided into three groups: severe, moderate, and mild DKA. Anthropometric, laboratory test, insulin, and glucose administration data were analyzed. The Glucose Infusion Rate (GIR), Insulin Infusion Rate (IIR), and GIR/IIR were calculated and used as indexes of insulin sensitivity. The area under the curve (AUC) for insulin and glucose infusion was calculated. RESULTS Moving among the three groups, IIR decreased while GIR and GIR/IIR increased from severe to mild DKA group (all p < 0.01). A similar trend was documented for AUC-insulin and AUC-glucose as well as AUC-glucose/AUC-insulin ratio. The Spearman correlation showed a negative correlation between pH and both IIR and AUC-Insulin as well as a positive correlation between pH and both GIR/IIR and AUC-glucose/AUC-insulin ratio. CONCLUSIONS Subjects with severe DKA have a higher insulin requirement compared to those with less severe DKA. Significant differences in terms of insulin sensitivity might be documented according to the severity of DKA, which might result in tailored insulin pH requirement in children with new onset type 1 diabetes.
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Affiliation(s)
| | - Nella Polidori
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Laura Comegna
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
| | - Angelika Mohn
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
| | - Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
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5
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Alshurtan KS, Alnizari O, Aldarwish H, Al-Tufaif AA. Efficacy and Safety of Intravenous Insulin in Treatment of Patient With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30721. [DOI: 10.7759/cureus.30721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/07/2022] Open
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Holder M, Kapellen T, Ziegler R, Bürger-Büsing J, Danne T, Dost A, Holl RW, Holterhus PM, Karges B, Kordonouri O, Lange K, Müller S, Raile K, Schweizer R, von Sengbusch S, Stachow R, Wagner V, Wiegand S, Neu A. Diagnosis, Therapy and Follow-Up of Diabetes Mellitus in Children and Adolescents. Exp Clin Endocrinol Diabetes 2022; 130:S49-S79. [PMID: 35913059 DOI: 10.1055/a-1624-3388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Martin Holder
- Klinikum Stuttgart, Olgahospital, Department of Pediatric Endocrinology and Diabetology, Germany
| | - Thomas Kapellen
- Department of Paediatrics and Adolescent Medicine, University Hospital, Leipzig, Germany
| | - Ralph Ziegler
- Practice for Paediatrics and Adolescent Medicine, Focus on Diabetology, Münster, Germany
| | - Jutta Bürger-Büsing
- Association of Diabetic Children and Adolescents, Diabetes Center, Kaiserslautern, Germany
| | - Thomas Danne
- Children's and Youth Hospital Auf der Bult, Hannover, Germany
| | - Axel Dost
- Department of Paediatrics and Adolescent Medicine, University Hospital Jena, Germany
| | - Reinhard W Holl
- Institute for Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Germany
| | - Paul-Martin Holterhus
- Department of General Paediatrics, University Hospital Schleswig-Holstein, Kiel Campus, Germany
| | - Beate Karges
- Endocrinology and Diabetology Section, University Hospital, RWTH Aachen University, Germany
| | - Olga Kordonouri
- Children's and Youth Hospital Auf der Bult, Hannover, Germany
| | - Karin Lange
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
| | | | - Klemens Raile
- Virchow Hospital, University Medicine, Berlin, Germany
| | - Roland Schweizer
- Department of Pediatrics and Adolescent Medicine, University Hospital Tübingen, Germany
| | - Simone von Sengbusch
- Department of Paediatrics and Adolescent Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Rainer Stachow
- Sylt Specialist Hospital for Children and Adolescents, Westerland, Germany
| | - Verena Wagner
- Joint Practice for Paediatrics and Adolescent Medicine, Rostock, Germany
| | | | - Andreas Neu
- Department of Pediatrics and Adolescent Medicine, University Hospital Tübingen, Germany
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8
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Dhatariya KK. The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care. Diabet Med 2022; 39:e14788. [PMID: 35224769 DOI: 10.1111/dme.14788] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/11/2022] [Indexed: 12/20/2022]
Abstract
This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14 mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05 units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medicine School, University of East Anglia, Norwich, UK
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9
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Maurice L, Julliand S, Polak M, Bismuth E, Storey C, Renolleau S, Dauger S, Le Bourgeois F. Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols. Eur J Pediatr 2022; 181:1497-1506. [PMID: 34993625 DOI: 10.1007/s00431-021-04332-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/24/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
UNLABELLED The best protocol for severe inaugural diabetic ketoacidosis (DKA) in children remains unclear. We compared two protocols by assessing effects during the first 24 h on osmolality, serum sodium, and glucose variations, which are associated with the risk of cerebral oedema, the most dreaded complication of DKA. We also recorded complications. We retrospectively included children aged 28 days to 18 years and admitted for severe DKA to either of two paediatric intensive care units (PICUs) in Paris (France). The two protocols differed regarding hydration volume, glucose intake, and sodium intake. From 17 June 2010 to 17 June 2015, 93 patients were included, 29 at one PICU, and 64 at the other. We compared severe glycaemic drops (> 5.5 mmol/L/h), mean glycaemia variations, serum sodium, serum osmolality, and the occurrence of cerebral oedema (CE) during the first 24 h after PICU admission. Severe glycaemic drops occurred in 70% of patients, with no between-group difference. Blood glucose, serum sodium, and serum osmolality variations were comparable. Seven (7.5%) patients were treated for suspected CE, (4 [10.3%)] and 3 [6.3%]) in each PICU; none had major residual impairments. CONCLUSION The two paediatric DKA-management protocols differing in terms of fluid-volume, glucose, and sodium intakes had comparable effects on clinical and laboratory-test changes within 24 h. Major drops in glycaemia and osmolality were common with both protocols. No patients had residual neurological impairments. WHAT IS KNOWN • Cerebral oedema is the most severe complication of diabteic ketoacidosis in children.The risk of cerebral oedema is dependant on both patient related and treatment-related factors. • The optimal protocol for managing severe inaugural diabetic ketoacidosis in children remains unclear, and few studies have targeted this specific population. WHAT IS NEW • Two management protocols that complied with ISPAD guidelines but differed regarding the amounts of fluids, glucose, and sodium administered produced similar outcomes in children with severe inaugural diabetic ketoacidosis. • Cerebral oedema was rare with both protocols and caused no lasting impairments.
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Affiliation(s)
- Laure Maurice
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Sébastien Julliand
- Paediatric Mobile Emergency Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Michel Polak
- Department of Paediatric Endocrinology, Gynaecology, and Diabetology, IMAGINE Affiliate, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Elise Bismuth
- Department of Paediatric Endocrinology and Diabetology, Robert Debré Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Storey
- Department of Paediatric Endocrinology and Diabetology, Robert Debré Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sylvain Renolleau
- Paediatric Intensive Care Unit, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Stéphane Dauger
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Fleur Le Bourgeois
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Grout S, Maue D, Berrens Z, Swinger N, Malin S. Diabetic Ketoacidosis With Refractory Hypokalemia Leading to Cardiac Arrest. Cureus 2022; 14:e23439. [PMID: 35494963 PMCID: PMC9038207 DOI: 10.7759/cureus.23439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 11/16/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is known to cause total body potassium depletion, but during initial presentation, very few patients are hypokalemic, and even fewer patients experience clinical effects. As the correction of acidosis and insulin drive potassium intracellularly, measured serum potassium levels decrease and require repletion. This phenomenon is well described, and severe hypokalemia necessitates delaying insulin therapy. Less well described is the kaliuretic nature of treatments of cerebral edema. We present a case of an adolescent male with new-onset type 2 diabetes who presented in DKA with signs of cerebral edema, hyperosmolarity, and hypokalemia. As insulin and cerebral edema therapy were initiated, his hypokalemia worsened despite significant IV repletion, eventually leading to ventricular tachycardia and cardiac arrest. Over the following 36 hours, the patient received >590 milliequivalents (mEq) of potassium. He was discharged home 12 days after admission without sequelae of his cardiac arrest.
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Saikia D, Mittal M, Kanakaraju C, Dhingra D, Kumar M. Efficacy and Safety of Low Dose Insulin Infusion against Standard Dose Insulin Infusion in Children with Diabetic Ketoacidosis- An Open Labelled Randomized Controlled Trial. Indian J Endocrinol Metab 2022; 26:173-179. [PMID: 35873943 PMCID: PMC9302420 DOI: 10.4103/ijem.ijem_50_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/12/2022] [Accepted: 03/30/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of low dose insulin infusion (0.05 U/kg/h) against the standard dose insulin infusion (0.1 U/kg/h) in children with diabetic ketoacidosis. METHOD Children (age <12 years, n = 30) presenting with diabetic ketoacidosis were enrolled and randomised to receive insulin infusion either as 0.05 U/kg/h (low dose) or 0.1 U/kg/h (standard dose) as an open labelled randomised controlled trial. The rest of the management was identical in both groups. The time taken for resolution of acidosis (pH ≥7.3 and HCO3 ≥15) was the primary outcome variable. The secondary outcome variables included the time taken until a decline in blood glucose to 250 mg/dl, the proportion of children developing hypoglycemia and hypokalemia, and any treatment failure. RESULTS The two groups were similar with respect to mean age, weight and gender distribution. New-onset diabetes was diagnosed on 24/30. The mean ± SD time for resolution of acidosis was similar between the groups; 27.0 ± 6.1 hours in the low dose group vs 23.4 ± 7.3 hours in standard dose group, P = 0.16. The mean time for the decline in blood glucose to 250 mg/dl was 13.0 ± 5.9 hours in low dose vs 11.6 ± 6.0 hours in standard dose group, P = 0.52. A lesser proportion of participants developed hypoglycemia and hypokalemia in the low dose group, though not statistically significant. There was no incidence of treatment failure in either group. CONCLUSION Low dose insulin infusion is equally effective and safe as standard dose insulin infusion in children with diabetic ketoacidosis.
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Affiliation(s)
- Diganta Saikia
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Medha Mittal
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | | | - Dhulika Dhingra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
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12
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Diagnostik, Therapie und Verlaufskontrolle des Diabetes mellitus im Kindes- und Jugendalter. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00769-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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13
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Rameshkumar R, Satheesh P, Jain P, Anbazhagan J, Abraham S, Subramani S, Parameswaran N, Mahadevan S. Low-Dose (0.05 Unit/kg/hour) vs Standard-Dose (0.1 Unit/kg/hour) Insulin in the Management of Pediatric Diabetic Ketoacidosis: A Randomized Double-Blind Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2255-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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14
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Hishida Y, Nakamura Y, Tsukiyama H, Nakagawa T, Sone M. A retrospective cohort study for the treatment of Asian diabetic ketoacidosis: optimizing initial doses of insulin. Acute Med Surg 2021; 8:e721. [PMID: 34976402 PMCID: PMC8705869 DOI: 10.1002/ams2.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/25/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Aim An insulin dose of 0.1 U/kg/h recommended by Western guidelines occasionally induces a precipitous decreasing blood glucose in Asian diabetic ketoacidosis (DKA). It is known that clinical factors, such as insulin sensitivity, differ between Asians and Americans/Europeans. We investigated how treatment options affect the time to DKA resolution to determine the optimal treatment for Asian DKA patients. Methods This was a retrospective cohort study from a single institution in Japan. A total of 34 adult DKA patients were observed. Baseline characteristics and treatment‐related parameters were compared between patients whose DKA was resolved within 18 h and those in which it was not. Results Significant differences were observed in the initial insulin dose (mean [standard deviation]: 0.053 [0.021] versus 0.031 [0.014] U/kg/h; P = 0.003) and the baseline β‐hydroxybutyrate (7.2 [3.2] versus 9.9 [2.6] mmol/L; P = 0.024) and HCO3− levels (11.2 [4.1] versus 7.7 [3.1] mmol/L; P = 0.014). Multivariable logistic regression analysis revealed that the initial insulin dose was significantly associated with early resolution of DKA and was independent of basal conditions. Receiver operating characteristic curve analysis indicated that the optimal cut‐off point for the initial insulin dose was 0.051 U/kg/h. With an initial insulin dose of 0.051 U/kg/h or higher, early resolution of DKA was obtained in 92.9% of patients. Conclusion An initial insulin dose of more than 0.05 U/kg/h provides an early resolution of DKA in Asian patients. Lower insulin doses significantly delay resolution. These results provide practical information for acute phase treatment of Asian DKA.
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Affiliation(s)
- Yoshiaki Hishida
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Yuta Nakamura
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hidekazu Tsukiyama
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Tomoko Nakagawa
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
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Pitocco D, Di Leo M, Tartaglione L, Rizzo EG, Caputo S, Rizzi A, Pontecorvi A. An Approach to Diabetic Ketoacidosis in an Emergency Setting. Rev Recent Clin Trials 2020; 15:278-288. [PMID: 32646361 DOI: 10.2174/1574887115666200709172402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic Ketoacidosis (DKA) is one of the most commonly encountered diabetic complication emergencies. It typically affects people with type 1 diabetes at the onset of the disease. It can also affect people with type 2 diabetes, although this is uncommon. METHODS Research and online content related to diabetes online activity is reviewed. DKA is caused by a relative or absolute deficiency of insulin and elevated levels of counter-regulatory hormones. RESULTS Goals of therapy are to correct dehydration, acidosis, and to reverse ketosis, gradually restoring blood glucose concentration to near normal. CONCLUSION It is essential to monitor potential complications of DKA and, if necessary, to treat them and any precipitating events.
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Affiliation(s)
- Dario Pitocco
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Mauro Di Leo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Linda Tartaglione
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Emanuele Gaetano Rizzo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Salvatore Caputo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Alessandro Rizzi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Alfredo Pontecorvi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
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Abstract
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, CA, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Kharode I, Coppedge E, Antal Z. Care of Children and Adolescents with Diabetes Mellitus and Hyperglycemia in the Inpatient Setting. Curr Diab Rep 2019; 19:85. [PMID: 31440933 DOI: 10.1007/s11892-019-1205-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Children and adolescents with acute hyperglycemia and diabetes mellitus frequently have acute, potentially life-threatening presentations which require high-acuity care in an inpatient and often intensive care setting. This review discusses the evaluation and care of hyperglycemia and diabetes mellitus in hospitalized children in both critical and non-critical care settings, highlighting important differences in their care relative to adults. RECENT FINDINGS Diabetic ketoacidosis remains highly prevalent at diagnosis among children with type 1 diabetes, and hyperglycemic hyperosmolar state is increasingly prevalent among children with type 2 diabetes. Recent clinical trials have investigated the potential benefits of various types of intravenous fluids and their rates of administration as well as the risks and benefits of intensive glucose control in critically ill children. The Endocrine Society has developed guidelines focused on managing hyperglycemic hyperosmolar state, outlining important aspects of care shown to decrease morbidity and mortality. In the non-critical illness setting, intensive therapy on newly diagnosed diabetes is increasingly recommended at the outset. With the increasing incidence of diabetes mellitus in children and adolescents, recent studies addressing acute diabetes emergencies help inform best practices for care of hospitalized children with hyperglycemia and diabetes.
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Affiliation(s)
- Ishita Kharode
- Division of Pediatric Endocrinology, Richmond University Medical Center, 355 Bard Avenue, Staten Island, NY, 10310, USA
| | - Emily Coppedge
- Weill Cornell Medicine, Division of Pediatric Endocrinology, NY Presbyterian Hospital, 505 East 70 Street, New York, NY, 10021, USA
| | - Zoltan Antal
- Weill Cornell Medicine, Division of Pediatric Endocrinology, NY Presbyterian Hospital, 505 East 70 Street, New York, NY, 10021, USA.
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18
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Lorenson JL, Cusumano MC, Stewart AM, Buhnerkempe MG, Sanghavi D. Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 27:380-385. [PMID: 30847977 DOI: 10.1111/ijpp.12525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/16/2019] [Indexed: 11/26/2022]
Abstract
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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Affiliation(s)
- Jessica L Lorenson
- HSHS St. John's Hospital, Springfield, IL, USA.,Southern Illinois University School of Pharmacy, Edwardsville, IL, USA
| | | | | | - Michael G Buhnerkempe
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA
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19
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 344] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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20
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Lopes CLS, Pinheiro PP, Barberena LS, Eckert GU. Diabetic ketoacidosis in a pediatric intensive care unit. J Pediatr (Rio J) 2017; 93:179-184. [PMID: 27770618 DOI: 10.1016/j.jped.2016.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/20/2016] [Accepted: 05/20/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To describe the characteristics of children aged 0-14 years diagnosed with diabetic ketoacidosis and compare the following outcomes between children with prior diagnosis of type 1 diabetes mellitus and children without prior diagnosis of type 1 diabetes mellitus length of hospital stay, severity on admission, insulin dosage, time of continuous insulin use, volume of fluids infused during treatment, and complications. METHODS A retrospective descriptive study with review of medical records of patients admitted to the pediatric intensive care unit of a referral hospital from June 2013 to July 2015. The following data regarding 52 admissions were analyzed: age, sex, weight, body surface area, signs, symptoms and severity on admission, blood gas, blood glucose, glycated hemoglobin, serum osmolarity, and index of mortality. The insulin dosage, time of continuous insulin use, volume administered in the expansion phase and in the first 24h, length of stay, and complications such as electrolyte disturbances, hypoglycemia, cerebral edema, and death were compared between the two groups. RESULTS Patients without a previous diagnosis of DM1 were younger at admission, with mean age of 8.4 years (p<0.01), reported more nausea or vomiting, polydipsia and polyuria, and showed more weight loss (p<0.01). This study also observed a higher prevalence of hypokalemia (p<0.01) and longer hospital stay in this group. CONCLUSIONS No differences in severity between groups were observed. The study showed that children without prior diagnosis of type 1 diabetes mellitus were younger at admission, had more hypokalemia during the course of treatment, and had greater length of hospital stay.
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Affiliation(s)
- Clarice L S Lopes
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil.
| | - Paula Pitta Pinheiro
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Luzia S Barberena
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Guilherme U Eckert
- Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
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21
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Lopes CL, Pinheiro PP, Barberena LS, Eckert GU. Diabetic ketoacidosis in a pediatric intensive care unit. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2016.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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22
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Edge JA, Nunney I, Dhatariya KK. Diabetic ketoacidosis in an adolescent and young adult population in the UK in 2014: a national survey comparison of management in paediatric and adult settings. Diabet Med 2016; 33:1352-9. [PMID: 26774013 DOI: 10.1111/dme.13065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 12/29/2022]
Abstract
AIMS To assess the management of diabetic ketoacidosis in young people, which differs in the UK between paediatric and adult services, and to evaluate outcomes and extent to which national guidelines are used. METHODS A standardized questionnaire was sent to all paediatric and adult diabetes services in England, requesting details of all diabetic ketoacidosis admissions in young people aged > 14 years in paediatric services ('paediatric' patients), and in young adults up to the age of 22 years in adult services ('adult' patients). RESULTS A total of 64 adult patients aged ≤ 22 years (mean age 19.2 years) were reported, of whom seven were aged between 10 and 16 years. A total of 71 paediatric patients were reported [mean (range) age 14.9 (11-18) years]. We found that 85% of paediatric and 69% of adult patients were treated according to national guidelines, 99% of paediatric and 89% of adult patients were treated with 0.9% saline and fixed-rate insulin infusions and 16% of adult patients received an insulin bolus. Insulin treatment was initiated later in paediatric patients than in adult patients (100 vs 39 min; P < 0.001). In 23% of adult patients and 8.8% of paediatric patients, potassium levels were < 3.5 mmol/l (P < 0.005). The lowest mean potassium levels were 3.8 mmol/l in paediatric and 3.5 mmol/l in adult patients (P < 0.005). Hypoglycaemia occurred in 42.3% of paediatric and 36% of adult patients. Time to resolution was similar in paediatric and adult patients (16.0 vs 18.2 h), as was duration of hospital stay (2.35 vs 2.53 days). CONCLUSIONS Young people were treated according to national guidelines, but the quality of monitoring was variable in both paediatric and adult settings. The incidence of hypoglycaemia and hypokalaemia was unacceptably high.
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Affiliation(s)
- J A Edge
- Oxford Children's Hospital, Headington, Oxford, UK.
| | - I Nunney
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - K K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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23
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Orwoll BE. Challenging the One-Dose-Fits-All Model for Insulin in the Acute Treatment of Pediatric Diabetic Ketoacidosis. A Critical Appraisal of "Low-Dose Versus Standard-Dose Insulin in Pediatric Diabetic Ketoacidosis: A Randomized Clinical Trial" by Nallasamy et al (JAMA Pediatrics 2014; 168:999-1005). Pediatr Crit Care Med 2016; 17:e477-e480. [PMID: 27509361 DOI: 10.1097/pcc.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the findings and discuss the implications of the use of low-dose insulin infusions in pediatric diabetic ketoacidosis compared with standard-dose insulin. DATA SOURCES A search of the electronic PubMed database was used to perform the clinical query as well as to search for additional relevant literature. STUDY SELECTION AND DATA EXTRACTION The article by Nallasamy K et al "Low-Dose vs Standard-Dose Insulin in Pediatric Diabetic Ketoacidosis: A Randomized Clinical Trial. JAMA Pediatrics 2014; 17:e477-e480" was selected for critical appraisal and literature review. DATA SYNTHESIS The authors performed a randomized controlled trial among 50 consecutive patients of 0-12 years old presenting to the emergency department in diabetic ketoacidosis. They found that low-dose (0.05 U/kg/hr) insulin infusion was noninferior to standard-dose (0.1 U/kg/hr) insulin in terms of resolution of hyperglycemia and acidosis with a trend toward lower rates of therapy-related complications in the low-dose group. CONCLUSIONS Low-dose insulin infusion is noninferior to standard-dose insulin in the treatment of younger pediatric patients with diabetic ketoacidosis and may lead to fewer therapy-related complications.
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Affiliation(s)
- Benjamin Edward Orwoll
- Division of Pediatric Critical Care, Department of Pediatrics, University of California San Francisco Benioff Children's Hospitals, San Francisco and Oakland, CA
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24
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Davis SM, Maddux AB, Alonso GT, Okada CR, Mourani PM, Maahs DM. Profound hypokalemia associated with severe diabetic ketoacidosis. Pediatr Diabetes 2016; 17:61-5. [PMID: 25430801 PMCID: PMC4896141 DOI: 10.1111/pedi.12246] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/29/2014] [Accepted: 10/30/2014] [Indexed: 02/06/2023] Open
Abstract
Hypokalemia is common during the treatment of diabetic ketoacidosis (DKA); however, severe hypokalemia at presentation prior to insulin treatment is exceedingly uncommon. A previously healthy 8-yr-old female presented with new onset type 1 diabetes mellitus, severe DKA (pH = 6.98), and profound hypokalemia (serum K = 1.3 mmol/L) accompanied by cardiac dysrhythmia. Insulin therapy was delayed for 9 h to allow replenishment of potassium to safe serum levels. Meticulous intensive care management resulted in complete recovery. This case highlights the importance of measuring serum potassium levels prior to initiating insulin therapy in DKA, judicious fluid and electrolyte management, as well as delaying and/or reducing insulin infusion rates in the setting of severe hypokalemia.
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Affiliation(s)
- Shanlee M Davis
- Children’s Hospital Colorado Pediatric Endocrinology, University of Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Children’s Hospital Colorado Intensive Care, University of Colorado Denver, Aurora, CO, USA
| | - Guy T Alonso
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Carol R Okada
- Children’s Hospital Colorado Intensive Care, University of Colorado Denver, Aurora, CO, USA
| | - Peter M Mourani
- Children’s Hospital Colorado Intensive Care, University of Colorado Denver, Aurora, CO, USA
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
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25
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A Multicenter Retrospective Survey regarding Diabetic Ketoacidosis Management in Italian Children with Type 1 Diabetes. J Diabetes Res 2015; 2016:5719470. [PMID: 26649321 PMCID: PMC4662990 DOI: 10.1155/2016/5719470] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 08/27/2015] [Indexed: 02/07/2023] Open
Abstract
We conducted a retrospective survey in pediatric centers belonging to the Italian Society for Pediatric Diabetology and Endocrinology. The following data were collected for all new-onset diabetes patients aged 0–18 years: DKA (pH < 7.30), severe DKA (pH < 7.1), DKA in preschool children, DKA treatment according to ISPAD protocol, type of rehydrating solution used, bicarbonates use, and amount of insulin infused. Records (n = 2453) of children with newly diagnosed diabetes were collected from 68/77 centers (87%), 39 of which are tertiary referral centers, the majority of whom (n = 1536, 89.4%) were diagnosed in the tertiary referral centers. DKA was observed in 38.5% and severe DKA in 10.3%. Considering preschool children, DKA was observed in 72%, and severe DKA in 16.7%. Cerebral edema following DKA treatment was observed in 5 (0.5%). DKA treatment according to ISPAD guidelines was adopted in 68% of the centers. In the first 2 hours, rehydration was started with normal saline in all centers, but with different amount. Bicarbonate was quite never been used. Insulin was infused starting from third hour at the rate of 0.05–0.1 U/kg/h in 72% of centers. Despite prevention campaign, DKA is still observed in Italian children at onset, with significant variability in DKA treatment, underlying the need to share guidelines among centers.
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26
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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27
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Wolfsdorf JI. The International Society of Pediatric and Adolescent Diabetes guidelines for management of diabetic ketoacidosis: Do the guidelines need to be modified? Pediatr Diabetes 2014; 15:277-86. [PMID: 24866064 DOI: 10.1111/pedi.12154] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 04/18/2014] [Indexed: 12/15/2022] Open
Abstract
The current version of the International Society of Pediatric and Adolescent Diabetes (ISPAD) guidelines for management of diabetic ketoacidosis (DKA) is largely based on the Lawson Wilkins Pediatric Endocrine Society/European Society of Pediatric Endocrinology (LWPES/ESPE) consensus statement on DKA in children and adolescents published in 2004. This article critically reviews and presents the most pertinent new data published in the past decade, which have implications for diagnosis and management. Four elements of the guidelines warrant modification: (i) The definition of DKA; (ii) insulin therapy; (iii) water and salt replacement; and (iv) blood ß-hydroxybutyrate measurements for the management of DKA.
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Affiliation(s)
- Joseph I Wolfsdorf
- Diabetes Program, Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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28
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Abstract
Diabetic ketoacidosis (DKA) is caused by absolute or relative lack of insulin. Lack of insulin leads to hyperglycemia, ketonemia, and acidosis. Prevalence of DKA at diagnosis of type 1 diabetes (T1D) varies around the world from 18 % to 84 %. Incidence of recurrent DKA is higher among females, insulin pump users, those with a history of psychiatric or eating disorder, and suboptimal socioeconomic circumstances. DKA is the most common cause of death in children with T1D. Children with DKA should be treated in experienced centers. Initial bolus of 10-20 mL/kg 0.9 % saline is followed by 0.45 %-0.9 % saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours. The prevention of DKA at diagnosis of diabetes can be achieved by an intensive community intervention and education of health care providers to raise awareness. Prevention of recurrent DKA requires continuous patient education and access to diabetes programs and telephone services.
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Affiliation(s)
- Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado Denver, School of Medicine, Aurora, CO 80045, USA.
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29
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Koves IH, Pihoker C. Pediatric diabetic ketoacidosis management in the era of standardization. Expert Rev Endocrinol Metab 2012; 7:433-443. [PMID: 30754163 DOI: 10.1586/eem.12.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Up to 70% of children with new-onset Type 1 diabetes mellitus (T1DM) present with diabetic ketoacidosis (DKA), with most cases initially assessed by their primary care provider. DKA is the most common cause of death in children with T1DM, mainly related to cerebral edema that occurs at a frequency of 0.15-4.6%. Early recognition of DKA can be improved by increasing the awareness of early clinical symptoms such as enuresis, polyuria and polydipsia. Clinical acumen paired with early assessment of patients with suspected T1DM and known T1DM, particularly if risk factors for DKA are present, can prevent serious complications and fatal outcomes. Urgent referral to specialist centers for suspected new-onset T1DM/DKA is required. A standardized approach is recommended to be followed to ensure successful initial management of DKA, both in the nonspecialist setting before transfer and in the more specialized hospital setting. This article outlines such a management approach.
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Affiliation(s)
- Ildiko H Koves
- b Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | - Catherine Pihoker
- a Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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30
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Piva JP, Garcia PC, Lago PM. A warning from India: hypovolemia may be as dangerous as excessive fluid infusion for cerebral edema in diabetic ketoacidosis. Pediatr Crit Care Med 2012; 13:236-7. [PMID: 22391841 DOI: 10.1097/pcc.0b013e3182257912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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31
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Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med 2011; 12:137-40. [PMID: 20473242 DOI: 10.1097/pcc.0b013e3181e2a21b] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare the effects of infusing insulin at 0.05 units/kg/hr rather than 0.1 units/kg/hr in children admitted to the intensive care unit with diabetic ketoacidosis. DESIGN A retrospective observational study. SETTING A tertiary pediatric intensive care unit. PATIENTS All children with diabetic ketoacidosis admitted during the 6-yr period from 2000 to 2005. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The effective plasma osmolality (plasma glucose concentration in mmol/L + twice the plasma sodium concentration in mmol/L), plasma glucose, plasma sodium, fluid intake, and acid-base status 12 hrs after the commencement of the insulin infusion. Compared to the 34 children who received 0.1 units/kg/hr of insulin, the 33 children who received 0.05 units/kg/hr of insulin were younger (median age, 25 mos vs. 62 mos, p = .024) and had a more gradual reduction in the effective plasma osmolality over the first 12 hrs (p < .0005); this was because plasma glucose decreased more slowly (p = .004) and plasma sodium increased faster (p < .0005). Both groups had a satisfactory improvement in acidosis and ketosis, and they had a similar length of stay in the intensive care unit. CONCLUSIONS Further studies are needed to evaluate the role of using 0.05 units/kg/hr of insulin to treat children with diabetic ketoacidosis. The smaller dose of insulin may make it easier to lower the effective plasma osmolality gradually and might, therefore, reduce the risk of cerebral edema.
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32
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Seewi O, Vierzig A, Roth B, Schönau E. Symptomatic cerebral oedema during treatment of diabetic ketoacidosis: effect of adjuvant octreotide infusion. Diabetol Metab Syndr 2010; 2:56. [PMID: 20723227 PMCID: PMC2936299 DOI: 10.1186/1758-5996-2-56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 08/19/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION A 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 PRESENTATION A 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. CONCLUSION Co-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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Affiliation(s)
- Ora Seewi
- Uniklinik Köln, Clinic for General Paediatrics, University Hospital of Cologne, Germany
| | - Anne Vierzig
- Uniklinik Köln, Clinic for General Paediatrics, University Hospital of Cologne, Germany
| | - Bernhard Roth
- Uniklinik Köln, Clinic for General Paediatrics, University Hospital of Cologne, Germany
| | - Eckhard Schönau
- Uniklinik Köln, Clinic for General Paediatrics, University Hospital of Cologne, Germany
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