MANAGEMENT OF DIABETIC KETOACIDOSIS AN HISTORICAL PERSPECTIVE

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MANAGEMENT OF DIABETIC KETOACIDOSIS AN
HISTORICAL PERSPECTIVE

• FOCUS ON INSULIN THERAPY

KGMM Alberti
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THE STARTING POINT
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CURRENT PRACTICE 1970-71
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• WHAT WAS THE BASIS FOR CURRENT PRACTICE?

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THE FIRST STUDIES 1922-23

• Nellis Foster
• Insulin doses 70 units in 6 hrs to 180 units in
  12 hrs
• The first dose may be 25 units at least, in
  adults, and repeated smaller doses at intervals
  of an hour or two

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KEY LATER STUDIES

• 1945 Root HF. The use of insulin and the abuse of
  glucose. JAMA
• 1949 Black AB Malins JM. Diabetic ketosis a
  comparison of results of orthodox and intensive
  methods of treatment based on 170 consecutive
  cases. Lancet

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DECLINE IN MORTALITY IN DIABETIC COMA (1)
Root
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DECLINE IN MORTALITY IN DIABETIC COMA (2)
Black Malins
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DECLINE IN MORTALITY IN DIABETIC COMA (3)
Harwood, 1951
518 units
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• N.B. Impact of big names and flawed studies on
  clinical practice

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INITIAL INSULIN REGIMEN 1971-72

• Based on Plasma Ketostix
• Range
• from 120 units IV 180 units IM
• to 30 units IV 50 units IM
• Alberti Hockaday, 1972

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INSULIN LEVELS WITH ORIGINAL OXFORD REGIMEN
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AIM OF INSULIN THERAPY

• High physiological levels
• Routes
• IV
• IM
• SC

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Alberti, Postgrad Med Journal 1973
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Alberti, Hockaday Turner, Lancet 1973
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Alberti, Hockaday Turner, Lancet 1973
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Page, Alberti, Greenwood et al BMJ 1974
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LOW DOSE INSULIN THERAPY FOR DIABETIC KETOACIDOSIS
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EARLIEST USE OF LOW DOSE INSULIN

• Katsch 1946
• Repeated IM SC injections of 4-10 units
  insulin every 15-60 mins
• 118 units in 12 hrs
• 166 units in 24 hrs

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CONCLUSIONS

• Why the high doses?
• Historical comparisons
• Inability to measure insulin
• Lack of appreciation of other factors

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OTHER ASPECTS OF DKA MANAGEMENT

• Early intensive rehydration (saline)
• Early potassium replacement
• Cautious use of bicarbonate
• Antibiotics
• Regular monitoring

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CONTINUING PROBLEMS

• Delays in management (immediate)
• Inadequate monitoring (hourly)
• Unnecessary mortality (avoidable)
• Cerebral oedema (? cause)
• ARDS

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CONCLUSION (1)

• Initial treatment of DKA
• - REHYDRATION more important than insulin!

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CONCLUSION (2)

• There is no substitute for
• meticulous attention to detail