Low-dose continuous intravenous insulin infusion in childhood diabetic ketoacidosis.

We studied 58 children with diabetic ketoacidosis using a random, prospective protocol, with insulin administered either as a low-dose continuous infusion or as high-dose intermittent subcutaneous injections. There were no statistically significant differences between admission pH and glucose determinations or the time to metabolic correction. The incidence of hypoglycemia and hypokalemia was higher in patients receiving subcutaneous insulin. Insulin levels in the low-dose patients were 85--160 microU/ml. The insulin required to achieve metabolic recovery was 1.6 U/kg in the low-dose group and 4.5 U/kg in the high-dose group (p less than 0.01). Glucose administered at a rate of 3 to 4 g er unit of insulin infused in the low-dose group maintained a serum glucose of 150 to 250 mg/dl. Our studies suggest that low-dose intravenous insulin therapy is safe, as effective as high-dose intermittent subcutaneous injections and avoids the risks of hypoglycemia and hypokalemia. Meticulous attention to individual patient care, however, must remain the most important single variable.     

Low-dose intravenous insulin infusion in patients with diabetic ketoacidosis: biochemical effects in children.

Twenty-five episodes of diabetic ketoacidosis in 20 children were treated with continuous low-dose intravenous insulin infusion. Stable serum immunoreactive insulin concentrations were produced, along with prompt falls in glucose, beta-hydroxybutyrate, and glucagon levels, and a steadily increasing bicarbonate level. Neither hypokalemia nor hypophosphatemia developed. Elevated serum alanine concentrations were found during ketoacidosis in contrast to the lowered concentrations found in adults, and were correlated inversely with plasma glucagon concentrations. The treatment regimen described is safe, easy to use, efficacious, and resulted in prompt correction of the observed biochemical alterations in children with diabetic ketoacidosis.     

Effectiveness of low-dose continuous intravenous insulin infusion in diabetic ketoacidosis. A prospective comparative study.

Twenty pediatric patients with diabetic ketoacidosis were randomly assigned in equal numbers to receive insulin either as a low-dose continuous intravenous infusion or as high-dose intermittent subcutaneous injections. Blood was obtained hourly for determinations of total CO2, plasma glucose, and osmolality, and, in previously untreated patients, plasma insulin. Serum values of beta hydroxybutyrate, electrolytes, and acetone were monitored every two hours. Plasma insulin levels were in the therapeutically effective range with each method of administration. There were no statistically significant differences in rate of correction of ketoacidosis, rate of reduction of plasma glucose, or decline in plasma osmolality. The incidence and the severity of hypokalemia were increased in the patients receiving subcutaneous insulin. There was less variation in the rate of reduction of plasma glucose in the infusion group. Low-dose continuous intravenous infusion of insulin is at least as effective in treating diabetic ketoacidosis as the traditional high-dose intermittent subcutaneous injection of insulin and offers some definite advantages.     

Low-dose intravenous insulin in the treatment of diabetic ketoacidosis.

Continuous slow intravenous infusion of insulin was used in 52 episodes of diabetic ketoacidosis. No complications of therapy, ie, hypoglycemia, induced hypokalemia, insulin resistance, or cerebral edema, were encountered. Potassium phosphate was given to 47 of the 52 patients. Sodium bicarbonate was administered to only one patient. The hyperglycemia frequently resolved more rapidly than the systemic acidosis; this was managed by adding glucose to the intravenous fluids when the blood sugar concentration decreased to approximately 250 mg/dL; insulin infusion, however, was continued until the acidosis was corrected (venous standard bicarbonate greater than 14 mEq/L). We have found this method of treatment to be safe and simple to administer, and we believe it is the preferred treatment of patients with diabetic ketoacidosis.     

Low-dose insulin infusion in the treatment of diabetic ketoacidosis: bolus versus no bolus

The effects of an initial iv bolus of insulin upon plasma glucose, blood gases, and electrolytes were assessed in 19 children with 20 episodes of diabetic ketoacidosis treated by a continuous low-dose insulin infusion of 0.1 unit/kg/hour. An iv bolus of insulin administered prior to low-dose insulin infusion accelerated the decline of plasma glucose concentration during the first hour of treatment, but differences in decline of mean plasma glucose concentration were not apparent thereafter. The mean time required for attaining "normoglycemia" (250 mg/dl) was similar, whether or not the initial bolus of insulin was given, with a smooth and predictable correction of initial hyperglycemia in the majority of children. However, an accelerated response was more frequent in those patients with compensated metabolic acidosis, who received an initial iv bolus of insulin; those with more severe metabolic acidosis took longer to recover. The data suggest that an initial iv bolus of insulin may not be required nor desirable in the majority of children with diabetic ketoacidosis treated by a standard low-dose insulin infusion regimen.     

Low-dose intravenous insulin therapy for diabetic ketoacidosis in children.

Fourteen pediatric patients were successfully treated for diabetic ketoacidosis with continuous low-dose intravenous insulin. The average admission blood glucose concentration was 717 mg/100 ml and the mean admission capillary blood pH was 7.13. The insulin dosage was 0.25 units/kg every four hours. The average total insulin dose for recovery was 0.6 units/kg. No complication was observed. The method is effective, safe, and simple to administer.     

Diabetic ketoacidosis and hyperosmolar diabetic coma in childhood. Low-dose continuous intravenous infusion of insulin (author's transl)]

Continuous intravenous infusion of low doses of insulin has been successfully used since 1972 in the treatment of "diabetic coma". The achieved levels of plasma insulin satisfy the transport of glucose and the inhibition of lipolysis. We are to report upon 8 children (mean age: 8.5 years), 6 with diabetic ketoacidosis and 2 with hyperosmolar diabetic coma. Blood sugar levels of 300 mg/dl or less were reached after averagely 8 hours of therapy and an average consumption of 0.8 U insulin/kg. Sodium and potassium levels, osmolality and acid base parameters for the first 24 hours are described. Low-dose continuous intravenous insulin infusion was effective, simple and safe in all cases. The presently recommended dosage of 0.1 insulin/kg x hour is to be used flexibly (range: 0.05--0.2 U/kg x hour). The administration of bicarbonate should be cautiously used for patients with severe acidosis. Infusion of hypotonic solutions as part of the treatment of the hyperosmolar diabetic coma can be dangerous. A new therapeutic regime based on our results is proposed.     

Low-dose continuous intravenous infusion of insulin on the first day of life in a diabetic ketoacidotic newborn

Onset of diabetes mellitus in the newborn is rare. Treatment at this young age using the low-dose continuous infusion of insulin as the method of choice, proved to have the advantages observed in older patients.     

Insulin allergy desensitization with simultaneous intravenous insulin and continuous subcutaneous insulin infusion

Abstract:  Persistent 'IgE-mediated' insulin allergy (type 1 allergy) (1) , unresponsive to changes in insulin type or the use of antihistamines, necessitates desensitization. A number of case reports (2–7) and recent reviews (8, 9) have demonstrated that desensitization can be achieved with continuous subcutaneous insulin infusion (CSII), but in type 1 diabetes mellitus, the need to slowly increase insulin dose from sub-therapeutic levels competes with the need for glycaemic control and suppression of ketogenesis. Tolerance to intravenous (IV) insulin despite persistent life-threatening allergic reactions to subcutaneous human insulin (bolus or CSII) has been recently described (10) . We present the cases of two unrelated 9-yr-old boys with persistent generalized urticarial reactions to subcutaneous injections of all available insulin types, despite treatment with oral antihistamines. After failed rapid desensitization to insulin delivered by either subcutaneous injection or CSII, the concurrent use of IV insulin allowed desensitization to CSII over 5–6 d.     

The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis

The use of an initial bolus of insulin prior to the initiation of low-dose insulin infusion therapy was evaluated in 56 episodes of diabetic ketoacidosis (DKA) in 38 children. The cases were randomly assigned to a group that received a bolus of insulin (n = 24) and to a group that did not (n = 32). After the first hour of insulin therapy, the decline in serum glucose level and the changes in serum osmolality were statistically similar in the two groups, regardless of the degree of acidosis. The time required to reach a serum glucose level of less than 250 mg/dl and the total duration of insulin infusion likewise were similar in the two groups. The use of a bolus of insulin at the onset of treatment for DKA appears unnecessary.     

Continuous subcutaneous insulin infusion versus multiple daily injections for type 1 diabetes

To review the literature on continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) to help the family of a 13‐year‐old girl with type 1 diabetes mellitus on MDI choose the best insulin delivery method for her to improve her glycaemic control. A literature search was performed to assess available evidence regarding CSII use versus MDI use for glycaemic control. We identified 15 relevant articles and present these, with a detailed analysis of a multicentre randomised controlled trial by Mueller‐Godeffroy et al. Although CSII use demonstrated a reduction in HbA_1c (?0.18 to ?0.7%) in some studies compared to MDI, this finding was not consistent across all studies. Mueller‐Godeffroy et al. did not find a statistically significant different in HbA_1c between CSII and MDI patients; however, additional benefits of insulin pump therapy, including improved diabetes‐related quality of life and reduced care giver burden, were reported. Further high‐quality randomised controlled trials and long‐term data are required to assess the benefits of CSII over MDI and the longevity of these methods.