A Comparative Effectiveness of Intravenous Fluids and Insulin Regimens in the Acute Management of Diabetic Ketoacidosis (DKA) and Hypoglycemia: A Systematic Review.

Abstract

Diabetic ketoacidosis (DKA) and hypoglycemia are acute metabolic emergencies requiring prompt and effective management in both adult and pediatric populations. Despite established protocols, variability in intravenous fluid and insulin regimens persists, necessitating a comprehensive evaluation of their comparative effectiveness across age groups. This systematic review aims to synthesize evidence on the efficacy and safety of different fluid and insulin strategies in managing DKA and hypoglycemia in diverse patient populations. Following PRISMA 2020 guidelines, a systematic search was conducted across PubMed, Embase, Web of Science, and Scopus. Nine studies (five randomized controlled trials (RCTs) and four cohort studies) were included after screening 227 records. Risk of bias was assessed using Cochrane RoB 2 for RCTs and the Newcastle-Ottawa Scale for cohort studies. Data were synthesized narratively due to clinical heterogeneity. Early subcutaneous insulin glargine with intravenous insulin reduced DKA resolution time (9.89 ± 3.81 vs. 12.73 ± 5.37 hours; p = 0.022) and hospital stay (4.75 vs. 15.25 days; p = 0.024) compared to intravenous insulin alone. Low-dose insulin (0.05 unit/kg/hour) in pediatric DKA showed comparable efficacy to the standard dose (0.1 unit/kg/hour), with fewer hypoglycemia (3.3% vs. 13.3%) and hypokalemia events (30% vs. 43.3%). Plasmalyte-148 accelerated metabolic acidosis resolution vs. sodium chloride (69% vs. 36% at 24 hours; p = 0.002). For hypoglycemia, 10% and 50% dextrose had similar efficacy, but 50% dextrose required higher doses and caused elevated post-treatment glucose (151.9 vs. 124.6 mg/dL; p = 0.001). Subcutaneous insulin protocols, low-dose insulin infusions, and balanced crystalloids optimize DKA management, while lower dextrose concentrations may suffice for hypoglycemia. Future research should prioritize multicenter RCTs to validate these findings.