Introduction: The British Society of Paediatric Endocrinology (BSPED) DKA guidelines endorse the use of subcutaneous (SC) insulin in clinically well patients. In our institution, routine practice is to use SC insulin to manage DKA patients, without clinical evidence of shock. We present safety and efficacy data.
Methods: A retrospective review of electronic records was performed to identify episodes of DKA (pH <7.30 or HC03<18 mmol/l and ketonaemia >3 mmol/l) managed with SC insulin, between 2011 and 2019. Cases managed with intravenous insulin or continuous subcutaneous insulin infusion (CSII) were excluded. Children without clinical shock (alert, with good peripheral perfusion, normal blood pressure at presentation) received an initial corrective dose of Novorapid insulin subcutaneously (0.1 units/kg <5 years, 0.2 units/kg >5 years), repeated every 4 h until readiness to eat was established. Children with nausea and vomiting received intravenous fluids. Descriptive characteristics including response to treatment and occurrence of complications in mild-moderate and severe DKA are presented.
Results: Sixty-nine cases of DKA were identified, of which 61 (88.4%) were managed with SC insulin. Eight episodes were excluded from the analysis: 4 cases managed with IV insulin, 3 cases with CSII, and 1 case of type 2 diabetes. Three patients were monitored on the paediatric intensive care unit. Mean age was 11.6 ± 4.2 years. Twenty-three (37.7%) episodes occurred in patients with new onset diabetes, thirty-six (59%) met criteria for mild-moderate DKA (pH≤ 7.20), and 25 (41%) for severe DKA (pH≤7.10). Resolution of DKA (pH≥7.3; clinically well) occurred within 24 hours in 52 (85.2%) episodes; that is in 91.6% of mild-moderate and 76% of severe DKA episodes, and in 78.3% of new onset versus 89.5% of known diabetics. Recurrence of DKA, hypokalaemia and hypoglycaemia occurred in 4.9%, 9.8% and 24.6% of episodes respectively. Median length of stay was 2 days. No cerebral oedema, cardiac arrhythmia, or death occurred. No switch from subcutaneous to intravenous insulin was required.
Conclusion: SC insulin appears to be a safe and effective alternative to IV insulin, in children and young people with DKA, without clinical shock at presentation. Our data support results published from institutions worldwide.
27 - 29 Nov 2019
British Society for Paediatric Endocrinology and Diabetes