Table 3

Evolution of treatment regimens for patients with diabetic coma and HHS

Years (reference nos.)Insulin therapyFluidsOther
Preinsulin era (13,14)NS/3% NS (s.c.)Alcohol, laxatives, alkalies, salicylate, oxygen inhalations, castor oil and citrate of potassium, camphor and ether, caffeine, circulatory stimulants
1930–1950 (17,27)20–100 units i.v. or s.c. bolus followed by 20 units s.c. every 30–60 min depending on glucosuriaNS (s.c. or i.v.) at variable ratesRoutine gastric lavage, cleansing enema, blood transfusion
1950–1970s (29,88,89)2 units/kg bolus of crystalline insulin; up to 920 units in the first 7 hNS followed by hypotonic solution ∼30 mL/kg or 600–800 cc × m2Gastric aspiration
Early 1970s (54,68,90)50 units i.v. bolus followed by 50–80 units/h i.v. or s.c.NS at 1–1.5 L over the first 2 h, followed by hypotonic solution at ∼100 mL/hAdd 20 mEq potassium to the second or third liter of fluid when potassium level is <6.0 mEq/L
Late 1970s (60,71)Low-dose insulin regimens. Regular insulin 0.1 units/kg i.v. followed by 0.1–0.3 units/h i.v., s.c., or i.m.NS at 1–2 L over the first 2 h, followed by NS or half NS. Add dextrose-containing solutions when glucose ∼250 mg/dLRisk of hypokalemia during insulin treatment identified. Early potassium replacement when serum potassium <5.5 mEq/L
1990s (7)0.1 units/kg i.v. bolus, then 0.1 units/kg/h as continuous infusion until glucose level <13.8 mmol/L (250 mg/dL)0.9% saline, 500–1,000 mL/h for 2 h, then switch to 0.45% saline at 250–500 mL/h. Add dextrose-containing solutions when glucose ∼250 mg/dLNo gastric lavage or gastric suction recommended
2004–2009 (4,87): ADA consensus for treatment of DKA and HHS in adult patientsInitial bolus (0.1 units/kg i.v.), followed by 0.1 units/kg/h until glucose <250 mg/dL, then reduce insulin by 50%NS at 500–1,000 mL/h for 2–4 h, then 0.45% saline at 250–500 mL/h
2011 (59): Pediatric Endocrine Society guidelines for treatment of HHS in childrenIn HHS: no intravenous insulin bolus, start at 0.025–0.05 units/kg/h when no decline in glucose with fluids alone; in hyperosmolar DKA: start 0.05–0.1 units/kg/h20 mL/kg NS bolus until adequate tissue perfusionDantrolene*
  • NS, normal saline (0.9% NaCl).

  • *If a malignant hyperthermia-like syndrome is suspected.