Treatment of Diabetic Ketoacidosis (DKA) with 2 Different Regimens Regarding Fluid Substitution and Insulin Dosage (0.025 vs. 0.1 units/kg/h)

Abstract

Aims:

Diabetic ketoacidosis (DKA) is still the most dangerous acute complication in type 1 diabetes. The aim of this study was to compare treatment of DKA with a regimen of a low insulin dose (0.025 units/kg/h) vs. a standard insulin dose (0.1 units/kg/h).

Methods:

We retrospectively analysed all cases of children and adolescents (age 0–18 years) with type 1 diabetes and DKA who needed treatment in the ICU in the time period of 1998–2005 in 2 pediatric diabetes centers. In a chart review of the first 48 h after onset of DKA the following parameters where evaluated: pH, blood glucose, sodium, potassium, and ketones in urine. Consciousness, neurological status and complications such as cerebral edema, hypoglycaemia or hypokalemia were also recorded.

Results:

23 children were treated in center A (low insulin dose) whereas 41 where treated in center B (standard insulin dose). Mean age of the patients was 8.9 (range 1.58–17.7) and 13.5 years (1.25–17.7) respectively (p=0.134). Mean pH was 7.1 and HCO3 was 9.05 and 7.79 respectively (p=0.122). Initial blood glucose was 26 mmol/l (no difference between the 2 centres). Treatment with the standard insulin dose resulted in a slightly shorter duration of acidosis (8 h in center A, 6.5 h in center B) and a significantly faster normalization of blood glucose (18 h in A, vs. 10.5 h in B) (p<0.005). During the first day we found similar and very low rates of hypoglycaemia. In center B one case of suspected cerebral edema and cerebral infarction occurred.

Conclusions:

Low dose insulin substitution is as safe as the recommended standard dose in respect to the occurrence of acute complications. Acidosis is broken slightly earlier with the standard dose. Implications of this earlier normalisation of pH remain unclear.

Key words

type 1 diabetes mellitus - diabetic ketoacidosis - children - adolescents - treatment - insulin

• References

• 1 Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 Units/kg/h in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med 2011; 12: 137-140
• 2 Bowden SA, Duck MM, Hofmann RP. Young children (<5 yr) and adolescents (>12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes 2008; 9: 198-201
• 3 Burghen GA, Etteldorf JN, Fisher JN et al. Comparison of high-dose and low-dose insulin by continuous intravenous infusion in the treatment of diabetic ketoacidosis in children. Diabetes Care 1980; 3: 15-20
• 4 Duck SC, Wyatt DT. Factors associated with brain herniation in the treatment of diabetic ketoacidosis. J Pediatr 1988; 113: 10-14
• 5 Dunger DB, Sperling MA, Acerini CL et al. European Society for pediatric endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 2004; 113: e133-e140
• 6 Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990–1996. Arch Dis Child 1999; 81: 318-232
• 7 Edge JA, Jakes RW, Roy Y et al. The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children. Diabetologia 2006; 49: 2002-2009
• 8 Gale EAM. The rise of childhood type 1 diabetes in the 20^th century. Diabetes 2002; 51: 3353-3361
• 9 Galler A, Stange T, Müller G et al. Rothe U for the Childhood Diabetes Registry in Saxony . Incidence of childhood diabetes in children aged less than 15 years and its clinical and metabolic characteristics at time of diagnosis: data from the Childhood Diabetes Registry of Saxony, Germany. Horm Res 2010; 74: 285-291
• 10 Glaser N, Barnett P, McCaslin I et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The pediatric emergency collaborative research committee of the American academy of pediatrics. N Engl J Med 2001; 344: 264-269
• 11 Kapellen TM, Heim K, Nietzschmann U et al. Changes in pediatric diabetes care in a 30-yr period at one institution for pediatric diabetology in Germany. Pediatr Diabetes 2002; 3: 70-73
• 12 Lawrence SE, Cummings EA, Gaboury I et al. Population based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr 2005; 146: 688-192
• 13 Luzi L, Barrett EJ, Groop LC et al. Metabolic effects of low dose insulin therapy on glucose metabolism in diabetic ketoacidosis. Diabetes 1988; 37: 1470-1477
• 14 Neu A, Hofer SE, Karges B et al. DPV initiative and the German BMBF Competence network for diabetes mellitus. Ketoacidosis at diabetes onset is still frequent in children and adolescents: a multicenter analysis of 14 664 patients from 106 institutions. Diabetes Care 2009; 32: e1647-e1648
• 15 Noyes KJ, Croffton P, Bath LE et al. Hydroybutyrate near-patient testing to evaluate a new endpoint for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children. Pediatr Diabetes 2007; 8: 150-156
• 16 Petzold S, Kapellen T, Siekmeyer M et al. Acute cerebral infarction and extra pontine myelinolysis in children with new onset type 1 diabetes mellitus. Pediatr Diabetes 2011; 12: 513-517
• 17 Puttha R, Cooke D, Subbarayan A et al. Low dose (0.05 units/kg/h) is comparable with standard dose (0.1 units/kg/h) intravenous insulin infusion for the initial treatment of diabetic ketoacidosis in children and adolescents with type 1 diabetes – an observational study. Pediatr Diabetes 2010; 11: 12-17
• 18 Onkamo P, Vaanenen S, Karvonen M et al. Worldwide increase in incidence of type 1 diabetes: the analysis of data on published incidence trends. Diabetologia 1999; 42: 1395-1403
• 19 Rosenbauer J, Icks A, Giani G. Incidence and prevalence of childhood type 1 diabetes mellitus in Germany – model-based national estimates. J Pediatr Endocrinol Metab 2002; 15: 1497-1504
• 20 Seewi O, Vierzig A, Roth B et al. Symptomatic cerebral oedema during treatment of diabetic ketoacidosis: effect of adjuvant octreotid infusion. Diabetol Metab Syndr 2010; 2: 56
• 21 Wolfsdorf J, Craig ME, Daneman D et al. Diabetic Ketoacidosis. ISPAD Consensus guidelines 2006–2007. Pediatr Diabetes 2007; 8: 28-43