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Insulin infusion via an intraosseous needle in diabetic ketoacidosis.

SUMMARY

We report the successful management of a five-year-old child with severe diabetic ketoacidosis with dehydration, who received his initial resuscitative fluids and a continuous infusion of insulin via an intraosseous needle. The patient had presented to a remote community hospital and intravenous access could not be gained. The correction of hyperglycaemia and metabolic acidaemia was achieved at a rate comparable to intravenous therapy. No complications were observed. Although intraosseous access is well described in paediatric resuscitation guidelines, it is not mentioned in International Diabetes Society guidelines for the management of diabetic ketoacidosis. Alternatives to intravenous administration of insulin delivery recommended in such guidelines, such as the subcutaneous or intramuscular routes, may be less appropriate than the intraosseous route. This route can also allow resuscitation fluids and other drugs to be reliably administered in children with diabetic ketoacidosis and severe dehydration where intravenous access can not be attained. We suggest that the potential role of intraosseous access, when intravenous access can not be obtained, should be considered when management guidelines for paediatric diabetic ketoacidosis with dehydration are reviewed.

Key Words: insulin, intraosseous, diabetic ketoacidosis, child

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The value of the intraosseous (IO) route for the emergency administration of drugs and fluids, when intravenous access cannot be attained, is well established (1-3). IO needle insertion is generally regarded as a safe, rapid and effective means of accessing the vascular system and has only rarely been associated with complications (2, 4). Although drugs such as atropine, adrenaline, sodium bicarbonate (5), adenosine (6) and succinylcholine (7) have been administered successfully via the IO route, the efficacy of insulin infused in this manner has not been described. We report a child with severe diabetic ketoacidosis (DKA), who was successfully treated with fluid and insulin administered via an IO needle.

CASE HISTORY

The Institutional Review Board of the University of Western Ontario required that informed consent be obtained from the parents of the patient to permit his treatment records to be used in compiling this report. This consent was obtained.

A previously healthy five-year-old boy presented to the emergency department of an isolated rural community hospital with a seven-day history of polyuria and polydipsia. On initial examination the child was unwell and drowsy. His blood pressure was 105/66 mmHg, heart rate 170 /min, respiratory rate 56 breaths/min and he had a temperature of 36.6 [degrees]C. The capillary refill time was four to five seconds. Initial blood analysis revealed marked hyperglycaemia (66.4 mmol/1) with metabolic acidaemia (pH 7.03, [P.sub.a][co.sub.2] 29 mmHg, HC[O.sub.3] 7.8 mmol/1 and base deficit 21.2 mmol/1). Urinanalysis revealed marked glycosuria and ketonuria. The serum sodium was 138 mmol/1 and the potassium was 5 mmol/1. A diagnosis of DKA was made. His condition was judged severe, on the basis of the degree of acidaemia and an estimated fluid deficit of 10%. Following multiple unsuccessful attempts to establish intravenous access, a 14 gauge, 3 cm disposable IO infusion needle (Cook[R] Critical Care, Bloomington, U.S.A.) was inserted into the anterior right proximal tibia. Fluid replacement and maintenance requirements were calculated to take account of his weight at presentation (21.8 kg) and the estimated degree of dehydration. Subsequent fluid and drug therapy was based on an assumed normal weight of 24 kg. Treatment was initiated via the IO needle with a bolus of NaCl 0.9% (10 ml.[kg.sup.-1]) and an insulin infusion (0.1 unit.[kg.sup.-1].[h.sup.-1]) was commenced. The cumulative fluid requirement to be met over a 48 to 60 hour period was estimated at 6000 ml. This fluid requirement was initially addressed with a continuous infusion of NaCl 0.9% (4 ml.[kg.sup.-1].[h.sup.-1]). Dextrose and potassium chloride were added to the 0.9% NaCl infusion as treatment demanded. The child was transferred by air transport to our paediatric critical care unit (PCCU). The combined rehydration and insulin therapy corrected the hyperglycaemia and acid base disturbance as shown in Figure 1. During the initial 14 hours of therapy, insulin was delivered through the 10 needle. After admission to PCCU, insertion of a peripheral venous cannula permitted the intravascular delivery of insulin and fluid. The patient made an uneventful recovery. No significant electrolyte abnormality occurred and no complication associated with the IO line was detected.

[FIGURE 1 OMITTED]

DISCUSSION

Diabetic ketoacidosis is one of the leading causes of morbidity and mortality in young children with type 1 diabetes mellitus (8). Establishing effective vascular access for the administration of fluid and insulin is a priority in children with moderate-to-severe DKA. However, venous cannulation can be difficult in the face of poor peripheral perfusion or in situations where experience in the cannulation of small children is absent. In such patients the recommendation made on behalf of national and international consensus groups (8-10) (Australia, Europe, U.S.A.) is to utilise the subcutaneous or intramuscular route for insulin administration. This advice is proffered despite reservations as to the efficacy of these routes of administration in patients with poor perfusion, as acknowledged (with supporting references), in the guidelines themselves. To the best of our knowledge, insulin administration by the IO route has not been reported in DKA and no mention of 10 insulin administration is made in the published treatment guidelines (8-10). This is surprising given the frequency with which haemodynamically compromised children are resuscitated using IO fluid administration.

The use of IO devices in the resuscitation of children was first reported in the 1940s and since 1986 the American Heart Association (AHA) has approved the use of the IO route for administration of fluids and medications during paediatric resuscitation. In their 2006 guidelines for paediatric basic and advanced life support (1, 2), the AHA and the International Liaison Committee on Resuscitation recommended the use of the IO route if vascular access was not rapidly achieved in any infant or child requiring IV drugs or fluids. Studies have showed that the IO route is safe, reliable and rapidly attained. In addition, placement of an IO needle requires less skill and practice than venous access either via peripheral, central or umbilical vein catheterisation (2). Crystalloids, colloids, drugs and blood products have all been successfully delivered to the systemic circulation via the IO route (11). It is generally recommended that standard IV doses are employed when administering drugs via the IO route (12). For continuous infusions, an infusion pump should be used to ensure adequate rates of drug delivery. The IO route is associated with a low rate of complications, with adverse effects being noted in less than 1% of patients. Unfortunately, when complications do arise they can be serious and include infection (13), fracture (14) and the extravasation of fluids leading to compartment syndrome (15).

Our patient received a standard dose (16) of insulin infusion (0.1 unit.[kg.sup.-1].[h.sup.-1]) via the IO route. The pattern of hyperglycaemic correction exhibited in our patient is consistent with an effect comparable to that achieved by the intravenous administration of insulin. We conclude that, in severe DKA when intravenous access is unattainable, the IO route will permit the efficient and safe administration of insulin and that the IO route is likely to be a superior means of administration than subcutaneous or intramuscular administration in those with dehydration resulting in compromised peripheral perfusion. Lastly, we believe that future guidelines and consensus statements should be amended to recognise the utility of IO insulin in the management of DKA where intravenous access can not be readily attained.

Accepted for publication on September 18, 2007

REFERENCES

(1.) International Liaison Committee on Resuscitation. The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: pediatric basic and advanced life support. Pediatrics 2006; 117:e955-977.

(2.) American Heart Association. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics 2006; 117:e989-1004.

(3.) Phillips B, Zideman D, Wyllie J, Richmond S, van Reempts P European Resuscitation Council Guidelines 2000 for Newly Born Life Support. A statement from the Paediatric Life Support Working Group and approved by the Executive Committee of the European Resuscitation Council. Resuscitation 2001; 48:235-239.

(4.) Fiorito BA, Mirza F, Doran TM, Oberle AN, Cruz EC, Wendtland CL et al. Intraosseous access in the setting of pediatric critical care transport. Pediatr Crit Care Med 2005; 6:50-53.

(5.) Driggers DA, Johnson R, Steiner JF, Jewell GS, Swedberg JA, Goller V Emergency resuscitation in children. The role of intraosseous infusion. Postgrad Med 1991; 89:129-132.

(6.) Friedman FD. Intraosseous adenosine for the termination of supraventricular tachycardia in an infant. Ann Emerg Med 1996; 28:356-358.

(7.) Tobias JD, Nichols DG. Intraosseous succinylcholine for orotracheal intubation. Pediatr Emerg Care 1990; 6:108-109.

(8.) Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TP et al. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child 2004; 89:188-194.

(9.) Wolfsdorf J, Glaser N, Sperling MA. American Diabetes Association: Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care 2006; 29:1150-1159.

(10.) Australasian Paediatric Endocrine Group Clinical practice guidelines: Type 1 diabetes in children and adolescents. NHMRC 2005.

(11.) Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric trauma patient. J Pediatr Surg 1993; 28:158-161.

(12.) Warren DW, Kissoon N, Mattar A, Morrissey G, Gravelle D, Rieder MJ. Pharmacokinetics from multiple intraosseous and peripheral intravenous site injections in normovolemic and hypovolemic pigs. Crit Care Med 1994; 22:838-843.

(13.) Stoll E, Golej J, Burda G, Hermon M, Boigner H, Trittenwein G. Osteomyelitis at the injection site of adrenalin through an intraosseous needle in a 3-month-old infant. Resuscitation 2002; 53:315-318.

(14.) Bowley DM, Loveland J, Pitcher GJ. Tibial fracture as a complication of intraosseous infusion during pediatric resuscitation. J Trauma 2003; 55:786-787.

(15.) Ribeiro JA, Price CT, Knapp DR Jr. Compartment syndrome of the lower extremity after intraosseous infusion of fluid. A report of two cases. J Bone Joint Surg Am 1993; 75:430-433.

(16.) Cardella E Insulin therapy during diabetic ketoacidosis in children. Acta Biomed 2005; 76 (Supp13):49-54.

K.A. ALAWI *, G.C. MORRISON ([dagger]), D.D. FRASER ([double dagger]), S. AL-FARSI ([section]), C. COLLIER **, A. KORNECKI ([dagger])([dagger]) Critical Care Unit, Department of Paediatrics, Children's Hospital of Western Ontario, University of Western Ontario and Children's Health Research Institute, London, Ontario, Canada

* M.D., ER.C.PC., Fellow in Emergency Medicine, Critical Care Unit, Department of Paediatrics, Children's Hospital of Western Ontario, University of Western Ontario.

([dagger]) M.R.C.P, Consultant in Paediatric Critical Care Unit, Assistant Professor in Pediatrics, Critical Care Unit, Department of Paediatrics, Children's Hospital of Western Ontario, University of Western Ontario.

([double dagger]) Ph.D., M.D., ER.C.PC., Consultant in Paediatric Critical Care Unit, Assistant Professor in Pediatrics, Critical Care Unit, Department of Paediatrics, Children's Hospital of Western Ontario, University of Western Ontario.

[section] M.D., M.R.C.PC.H.(U.K.), Fellow in Emergency Medicine, Critical Care Unit, Department of Paediatrics, Children's Hospital of Western Ontario, University of Western Ontario.

** B.Sc.N., Nurse, Critical Care Unit, Department of Paediatrics, Children's Hospital of Western Ontario, University of Western Ontario. ([dagger]) ([dagger]) M.D., Consultant in Paediatric Critical Care Unit, Assistant Professor in Pediatrics, Children's Hospital of Western Ontario, University of Western Ontario.

Address for reprints: Dr A. Kornecki, Paediatric Critical Care Unit, Children's Hospital of Western Ontario, 800 Commissioners Road East, London, Ontario N6C 2V5, Canada.
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Article Details
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Author:Alawi, K.A.; Morrison, G.C.; Fraser, D.D.; Al-Farsi, S.; Collier, C.; Kornecki, A.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:1CANA
Date:Jan 1, 2008
Words:1948
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