Insulin and Sodium Bicarbonate

Treatment of Diabetic Ketoacidosis

in Children
Churku Mohan Reddy, MD, and Eduardo Orti, MD
Nashville, Tennessee and Brooklyn, New York

Nineteen patients, nine males and ten females had 24 episodes of All patients received crystalline in-
diabetic ketoacidosis. Infection was the precipitating factor in the sulin subcutaneously. Some of the pa-
development of ketoacidosis. Recovery of ketoacidosis occurred tients were receiving crystalline insulin
with 0.7 units of crystalline insulin per kg of body weight. The intravenously and those cases were not
insulin requirement is less than the generally recommended dose. included in the study. Antibiotic ther-
apy was given where indicated.
Hypoglycemia, hypokalemia, and alkalosis were not developed in
our children. Ketoacidosis was adequately corrected by 2.5 mEq of Results
sodium bicarbonate per kg of body weight. Of the 19 patients, nine were males
and ten were females. They ranged in
age from three to 13.6 years. Polyuria,
nocturia, polydipsia, polyphagia, loss
of weight, and weakness were common
Many different regimes have been Ten children were known diabetics presenting symptoms of diabetic keto-
advocated regarding insulin adminis- and nine were new cases. Patients with acidosis in new cases. Abdominal pain
tration and amount, as well as various presence of glycosuria, ketonuria, and and vomiting were presenting symp-
schedules of electrolyte therapy. The severe acidosis (blood pH less than 7.2 toms in new as well as in established
administration of sodium bicarbonate or plasma bicarbonate level less than cases (Table 1). Infection was the pre-
has been the subject of repeated dis- 12 mEq per liter) were included in the cipitating factor in 18 episodes, avoid-
cussion. None of the proposed thera- study. Blood was drawn and levels ance of insulin for more than 24 hours
peutic approaches has been universally were determined by standard labora- in three episodes and the precipitating
accepted. Krumlik and associates1 re- tory procedures for serum sodium, po- factor was unknown in three episodes.
viewed the treatment of 44 episodes of tassium, chloride, glucose, calcium, The means and ranges of values for
diabetic ketoacidosis in 27 children. phosphorus, and blood gases before the blood sugar, pH, serum bi-
They postulated that children with the initiation of intravenous fluids. carbonate, and insulin and bicarbonate
ketoacidosis can be adequately treated The serum bicarbonate was calculated requirements are summarized in Table
by less than 1 unit of crystalline insu- from the pH and pCo2 by using the 2. An average time of 4.9 hours was
lin per kg of body weight. We have Singer-Hastings nomogram. required to raise the pH from 7.07 to
reviewed the record of 19 patients All patients were initially infused 7.23.
with 24 episodes of ketoacidosis and with 0.9 percent sodium chloride, un- A mean of 0.54 units of crystalline
correlated the amounts of insulin and til blood gas results were obtained. If insulin and 2.5 mEq of sodium bi-
sodium bicarbonate with the effects the initial blood pH was less than 7.2 carbonate per kg of body weight was
produced. or serum bicarbonate level less than 12 required to produce the above effect.
mEq per liter, the isotonic sodium Complete recovery from ketoacidosis
chloride solution was replaced with took an average of 9.6 hours and was
Materials and Methods half-isotonic bicarbonate in five per- achieved by receiving a mean of 0.7
Nineteen children were admitted to cent dextrose solution. When blood units of crystalline insulin per kg of
Kings County Hospital of Brooklyn pH rose to 7.2, electrolyte solution body weight.
and Hubbard Hospital of Meharry containing potassium was given in the All children recovered from their
Medical College from 1971 to 1975. amount of not more than 3 mEq of ketoacidosis without occurrence of
potassium per kg of body weight per hypoglycemia or hypokalemia.
24 hours, if the child had voided. In
those cases in which the child was al- Discussion
Requests for reprints should be addressed to ready receiving electrolyte solution A review of Harwood 2 revealed
Dr. Churku Mohan Reddy, Endocrine and which contain potassium this was not
Metabolism Unit, Department of Pediatrics, very high recommended doses of insu-
Meharry Medical College, Nashville, Tenn done. lin (130 to 56,000 units) in 24 hours
37208

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977

 Table 1. Clinical Features and Their Incidence in Diabetic Ketoacidosis (24 Episodes)

Clinical Features Percentages of Incidence

Established Cases New Cases
(15 episodes) (9 episodes)

Polyuria, polydipsia 13 100

Vomiting 60 55
Abdominal pain 46 44
Nocturia 13 77
Polyphagia - 55
Loss of weight - 44
Weakness - 44
Lethargy, drowsiness - 22
Average weight 93 66
Underweight 6 22
Overweight - 11
Constipation - 11
URTI 40 44
Tonsillitis 13 11
Abscess 6
Otitis media 13
Fever 6
Enteritis - 11
Insulin avoidance 20

for adults. No difference in clinical re-
sponse was found between groups of
patients receiving 80, 160, or 240
units of crystalline insulin initially.3
Similar results were reported by Shaw
and associates4 with low or high dose
insulin. Using a regime of frequent
doses of 5-10 units per hour of intra-
muscular insulin also produced uni-
form response in adults.5 Recently,
Mosley6 reported similar results with
small doses of intramuscular insulin in
twelve children. Peter7 suggested in
1952 that large doses of insulin may
not be necessary in adults in the treat-
ment of diabetic ketoacidosis. Krumlik
and associates' found from their retro-
spective review, diabetic ketoacidosis
in infants and children can be ade-
quately treated by less than 1 unit of
insulin per kg of body weight and they
recommend 0.5 units per kg of body
weight as an initial dose. Our results
are similar to the Krumlik observations
and we recommend not more than 0.5
unit of crystalline insulin per kg of
body weight as an initial dose.
Weil8 and Kaye9 discussed the con-
troversy regarding bicarbonate admin-
istration in the treatment of keto-
acidosis. Munk and associatesl0 found
that bicarbonate therapy does not af-
fect oxygen transport in juvenile dia-
betic ketoacidosis. But very low pH
has adverse effects on the respiratory
center1 1 and on myocardial contrac-
tility. 1 2,1 3Zimmet 14suggested to in-
fuse an arbitrary dosage of 2.0-2.5
mEq per kg of sodium bicarbonate, to
patients who need this agent. We re-
stricted the use of bacarbonate thera-
py to those children with a pH less
than 7.2 and they received 2.5 mEq of
NaHCO3 per kg of body weight to
raise the pH from 7.07 to 7.23 with-
out any side effects. The children re-
viewed did not receive alkali therapy
once the pH rose to 7.2.

356 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
 Table 2. Diabetic Ketoacidosis (24 episodes)

At Admission Defined Value* Complete Recoveryt

Time (hr) Time (hr) Time (hr)
Range Mean Range Mean
0 1-11 4.9 2-22 9.6
Biochemical Values Range9 Mean Range Mean Range Mean

Blood Sugar
(mg/100 ml) 250-2500 566 120-750 341 107-340 186
pH 6.8-7.18 7.07 7.2-7.27 7.23 7.3-7.42 7.32

Serum bicarbonate
(mEq/liter) 3-11.5 6.45 6-17 11.34 11-18 15.8
Insulin
(Units per kg
of body weight) - - 0.26-1.08 0.54 0.31-1.62 0.70
Sodium bicarbonate
(mEq per kg
of body weight) - - 0.3-8.91 2.5

*pH equal to or greater than 7.2 and serum bicarbonate equal to or greater than 12
mEq per liter or both.
tpH equal to or greater than 7.3 and serum bicarbonate equal to or greater than 20
mEq per liter or both.

83:268-271, 1973 9. Kaye R: Diabetic ketoacidosis -the

Acknowledgement
The authors wish to express their appre-
ciation to Mrs. Sharon Sowell for her assis-
tance in the preparation of this paper.
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