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

Ben Forestell, MD; Frank Battaglia, MD; Sameer Sharif, MD; Mohamed Eltorki, MBChB; M. Constantine Samaan, MD, MSc; Karen Choong, MBChB, MSc; Bram Rochwerg, MD, MSc

doi:10.1097/CCE.0000000000000857

Critical Care Explorations (Feb 2023)

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

Ben Forestell, MD,
Frank Battaglia, MD,
Sameer Sharif, MD,
Mohamed Eltorki, MBChB,
M. Constantine Samaan, MD, MSc,
Karen Choong, MBChB, MSc,
Bram Rochwerg, MD, MSc

Affiliations

Ben Forestell, MD: 1 Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
Frank Battaglia, MD: 1 Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
Sameer Sharif, MD: 1 Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
Mohamed Eltorki, MBChB: 4 Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Hamilton, ON, Canada.
M. Constantine Samaan, MD, MSc: 3 Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
Karen Choong, MBChB, MSc: 3 Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
Bram Rochwerg, MD, MSc: 2 Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.

DOI: https://doi.org/10.1097/CCE.0000000000000857
Journal volume & issue: Vol. 5, no. 2
p. e0857

Abstract

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OBJECTIVES:. 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.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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