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Published on: June 11, 2012
Insulin Infusion Dosing in Pediatric Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized
Ben Forestell1, Frank Battaglia1, Sameer Sharif1,2,3
1Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
Insights
Low-dose insulin infusion for pediatric diabetic ketoacidosis (DKA) appears as effective as standard doses. This approach likely reduces adverse events like hypokalemia and hypoglycemia in children with DKA.
Area of Science:
- Pediatric Endocrinology
- Metabolic Disorders
- Critical Care Medicine
Background:
- Diabetic ketoacidosis (DKA) is a serious complication of diabetes in children.
- Insulin infusions are the primary treatment for pediatric DKA, but optimal dosing is debated.
- Understanding the efficacy and safety of different insulin infusion rates is crucial for clinical practice.
Purpose of the Study:
- To compare the efficacy and safety of low-dose (0.05 units/kg/hr) versus standard-dose (0.1 units/kg/hr) intravenous insulin infusions in treating pediatric DKA.
- To evaluate the impact of different insulin doses on key clinical outcomes and adverse events.
Main Methods:
- A systematic literature search was conducted across major databases (MEDLINE, EMBASE, PubMed, Cochrane) up to April 2022.
- Included studies were randomized controlled trials (RCTs) involving children with DKA.
- Data were extracted and analyzed using a random effects model, with certainty of evidence assessed using GRADE.
Main Results:
- Four RCTs with 190 participants were included.
- Low-dose insulin infusion showed no significant difference in time to resolution of hyperglycemia or acidosis compared to standard-dose.
- Low-dose insulin infusion was associated with a probable decrease in hypokalemia and hypoglycemia incidence, with low certainty for the rate of blood glucose change.
Conclusions:
- Low-dose insulin infusion is likely as effective as standard-dose for treating pediatric DKA.
- The low-dose regimen probably reduces treatment-related adverse events, including hypokalemia and hypoglycemia.
- Study limitations include imprecision in outcome data and limited generalizability due to single-country studies.
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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