Diabetic ketoacidosis: ketones fell faster on an extended insulin regimen.

Clinical bottom line (level 1b)

  1. Patients with diabetic ketoacidosis who receive an extended insulin regimen have a more rapid fall in ketones than those on a conventional regimen (~16 hours difference).
  2. The clinical significance of this is unclear.
Wiggam et al: Diabetes Care 1997; 20: 1347-1351
Expires October 2003

The study

Unblinded concealed randomised trial with intention-to-treat
Setting: university hospital, UK

22 patients (aged mean 30 years, 68% female) diabetic ketoacidosis (defined as clinical features of uncontrolled diabetes requiring emergency hospital admission, pH <7.25 or blood bicarbonate <16 mmol/l and capillary blood 3-hydroxybutyrate >1.5 mmol/l)
Control Group: (n = 10, 10 analysed): conventional insulin regimen- insulin 20 units im bolus, followed by infusion of five units per hour iv, continued until blood glucose 10 mmol/l or less
Experimental Group: (n = 12, 12 analysed): extended insulin regimen- insulin 20 units im bolus, followed by insulin infusion five units per hour iv, continued until blood glucose 10 mmol/l or less. Continued with 20% glucose once blood glucose 5 to 10 mmol/l until 3-hydroxybutyrate <0.5 mmol/l
Patients then started 5% glucose and insulin infusion (at 8 units/hour) with subcutaneous insulin as necessary to maintain blood glucose <10 mmol/l.
100% followed for 24 hours

The evidence

Outcome Control Group
(SD)		 Experimental Group
(SD)		 Mean Difference
(95% CI)
time to glucose <10 mmol/l 3.4
(1.3) 		5.1
(3.5) 		-1.7
(-4.2 to -0.75)
time to 3-hydroxybutyrate <1.5 mmol/l 21.8
(10.8) 		5.9
(2.8) 		16
(9.2 to 23)

Comments

  1. Data analysis was confounded by statistically significant reduction in serum 3-hydroxybutyrate levels in patients receiving prolonged insulin infusion prior to onset of infusion. This required analysis of covariance to correct for initial baseline differences. Even overlooking statistical issues, no statistically significant difference in final CO2 contents was noted, suggesting correction of acidosis was not speeded up. The procedure also requires use of bedside monitoring of 3-hydroxybutyrate (not re

Citation

  1. Wiggam MI, O'Kane MJ, Hadden DR, et al: Treatment of diabetic ketoacidosis using normalization of blood 3-hydroxybutyrate concentration as the endpoint of emergency management. Diabetes Care 1997; 20: 1347-1351
Search Terms: ketoacid* in Cochrane
Contributor: Chris Ball and Musab Hayatli, July 2000
Reviewer: Jon Levine

Clinical Question.
Patient patients suffering from Diabetes Ketoacidosis
Intervention or Exposure extended insulin regimen
Comparison conventional regimen
Outcome fall in ketones