Insulin Infusion Dosing in Pediatric Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Ben Forestell; Frank Battaglia; Sameer Sharif; Mohamed Eltorki; M Constantine Samaan; Karen Choong; Bram Rochwerg

doi:10.1097/CCE.0000000000000857

Insulin Infusion Dosing in Pediatric Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Crit Care Explor. 2023 Feb 17;5(2):e0857. doi: 10.1097/CCE.0000000000000857. eCollection 2023 Feb.

Authors

Ben Forestell¹, Frank Battaglia¹, Sameer Sharif^{1

2

3}, Mohamed Eltorki⁴, M Constantine Samaan^{3

5}, Karen Choong^{3

6}, Bram Rochwerg^{2

3}

Affiliations

¹ Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
² Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
³ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
⁴ Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Hamilton, ON, Canada.
⁵ Department of Pediatrics, Division of Pediatric Endocrinology, McMaster University, Hamilton, ON, Canada.
⁶ Department of Pediatrics, Division of Pediatric Critical Care, McMaster University, Hamilton, ON, Canada.

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.

Keywords: critical care; diabetes mellitus; diabetic ketoacidosis; drug dosing; insulin.

Publication types

Review