Evolution of treatment regimens for patients with diabetic coma and HHS
| Years (reference nos.) | Insulin therapy | Fluids | Other |
|---|---|---|---|
| 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 glucosuria | NS (s.c. or i.v.) at variable rates | Routine 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 h | NS followed by hypotonic solution ∼30 mL/kg or 600–800 cc × m2 | Gastric 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/h | Add 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/dL | Risk 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/dL | No gastric lavage or gastric suction recommended |
| 2004–2009 (4,87): ADA consensus for treatment of DKA and HHS in adult patients | Initial 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 children | In 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/h | 20 mL/kg NS bolus until adequate tissue perfusion | Dantrolene* |
NS, normal saline (0.9% NaCl).
↵*If a malignant hyperthermia-like syndrome is suspected.