One hundred years ago: the dawning of the insulin era

The dawn of the insulin era can be placed in 1921, when Banting and Best started their experiments which led, a year later, to the successful treatment of diabetes. They were preceded by the discoveries of the pancreatic cause of diabetes by Minkowski and von Mering in 1889 and of the islets by Paul Langerhans in 1869. The achievement of the first targeted treatment in medical history was a landmark of medical progress. However, it was accompanied by a mixture of human greatness and misery. Genius and recklessness, ambition and deception, camaraderie and rivalry, selflessness and pursuit of glory went along with superficial search of the existing literature, poor planning, faulty interpretation of results, failure to reproduce them, and misquoting of reports from other laboratories. Then as now, such faults surface whenever human nature aims to push forward the boundaries of knowledge and pose a real challenge in today's world, as the scientific method strives to keep healthy in the face of growing anti-scientific feelings.

[Insulin: initiation of pool of insulin-dependent cells, targeted transfer of triglycerides and increase of kinetic parameters of oxidation of fatty acids]

The insulin, to provide with energy the biological function of locomotion, formed: a) pool of phylogenetically late insulin-dependent cells; b) highly productive vector variant of transfer of saturated and mono unsaturated fatty acids only to insulin-dependent cells; c) new variant of active absorption of substrates for acquiring energy by cells--apoE/B-100-receptor endocytosis; d) transformation of all endogenically synthesized palmitic saturated fatty acid in oleic mono saturated fatty acid and e) replacement of potentially ineffective palmitic variant of formation of energy in vivo with potentially high-performance oleic variant of metabolism of substrates for turning out of ATP. The insulin expressed synthesis of apoE glucose carrier 4 and stearyl-KoA-desaturase. These occurrences confirm that syndrome of insulin resistance primarily is the pathology of metabolism of fatty acids and only secondary the pathology metabolism of glucose. The multi-functional fatty cells of visceral areolar tissue and specialized adipocytes of subcutaneous fat depots are phylogenetically, regulatory and functionally different cells. They are formed under development of different biological functions: the first ones under realization of biological function of trophology and second ones under realization of biological function of locomotion. At the level of organism, the mechanisms of hypothalamus-fatty cells feedback are realized by peptide leptin and in case of hypothalamus-adipocytes feedback--peptide adiponectin. The potential possibilities of mitochondria in synthesis of ATP are high and are conditioned only by amount of substrate of mitochondria acetyl-KoA. This shortage can be chronic as in cases of disorder of insulin function and palmitic variant of metabolism of substrates for acquiring energy by cells. The deficiency of acetyl-KoA can be acute as is the case of diabetic coma when surplus amount of ketonic bodies follows the expressed deficiency of acetyl-KoA formed from glucose and fatty acids. Can the intravenous injection of acetyl-KoA be effective under diabetic ketoacidosic coma?

[Hypoglycaemic coma due to falsely elevated glucose values in a patient with diabetes mellitus and peritoneal dialysis]

A 45-year-old female diabetes-mellitus patient on peritoneal dialysis was admitted because of vertigo. During her stay in hospital she developed a comatose condition with abnormal head posture and deviation ofthe eyes to the left. Capillary blood from the fingertip showed a glucose value of 15.4 mmol/l. However, the automatically obtained glucose value delivered with a blood-gas analysis was found to be 1.2 mmol/l. The neurological state of the patient normalised fully after intravenous glucose administration. The glucose values were falsely elevated because the patient used a peritoneal dialysis fluid at night which contained icodextrin as an osmotic agent. Metabolites of icodextrin can influence blood-glucose measurements taken using analyzers that depend on the enzyme glucose dehydrogenase. To prevent potentially life-threatening situations, the use of an adequate glucose meter is of paramount importance.

Profound hypokalemia in diabetic ketoacidosis: a therapeutic challenge

OBJECTIVE

To describe profound hypokalemia in a comatose patient with diabetic ketoacidosis.

METHODS

We present a case report, review the mechanisms for the occurrence of hypokalemia in diabetic ketoacidosis, and discuss its management in the setting of hyperglycemia and hyperosmolality.

RESULTS

A 22-year-old woman with a history of type 1 diabetes mellitus was admitted in a comatose state. Laboratory tests revealed a blood glucose level of 747 mg/dL, serum potassium of 1.9 mEq/L, pH of 6.8, and calculated effective serum osmolality of 320 mOsm/kg. She was intubated and resuscitated with intravenously administered fluids. Intravenous administration of vasopressors was necessary for stabilization of the blood pressure. Intravenous infusion of insulin was initiated to control the hyperglycemia, and repletion of total body potassium stores was undertaken. A total of 660 mEq of potassium was administered intravenously during the first 12.5 hours. Despite such aggressive initial repletion of potassium, the patient required 40 to 80 mEq of potassium daily for the next 8 days to increase the serum potassium concentration to normal.

CONCLUSION

Profound hypokalemia, an uncommon initial manifestation in patients with diabetic ketoacidosis, is indicative of severe total body potassium deficiency. Under such circumstances, aggressive potassium repletion in a comatose patient must be undertaken during correction of other metabolic abnormalities, including hyperglycemia and hyperosmolality. Intravenously administered insulin should be withheld until the serum potassium concentration is (3)3.3 mEq/L.

[Diabetic coma and hypoglycemia in children. What to do when in an emergency]

With a few very rare exceptions, hypoglycemia and diabetic coma almost always occur in patients with diabetes mellitus, and are among the most common emergencies in children. For the emergency physician, it is important, on the basis of a specific history-taking and information from, for example, family members, supplemented by a clinical examination done in the light of knowledge of the typical symptoms of each of the entities, to determine whether hypoglycemia or diabetic coma is presenting. The most important technical examination is the measurement of blood glucose. In the event of hypoglycemia, the first therapeutic measure is the administration of sugar--in the case of a comatose patient via a venous line. The s.c. or i.m. administration of glucagon to achieve short-term improvement might be considered. In the event of a diabetic coma, abundant electrolyte solution is initially needed, followed by i.v. insulin. Referral to hospital is mandatory.

Diabetic keto-acidotic (DKA) coma following olanzapine initiation in a previously euglycaemic woman and successful continued therapy with olanzapine

We report the case of a euglycaemic woman whose glucose control rapidly decompensated following olanzapine initiation leading to diabetic coma. Hyperglycaemia has been associated with chronic psychotic disorders and antipsychotics for many years. However, it is unusual to see such rapid and life-threatening changes associated with treatment. The case highlights that changes in antipsychotic treatment may be associated with large changes in glucose tolerance, and that it is possible to continue antipsychotic treatment with appropriate diabetic care.

Reversal of foetal hydrops and foetal tachyarrhythmia associated with maternal diabetic coma

Foetal hydrops is always a challenge for the clinician. We report a case of tachycardia associated with hydrops and hydramnios in a pregnancy complicated with diabetic coma at 28 weeks gestation. Normal foetal heart rate was recorded immediately after correction of maternal acidotic status and hydrops eventually disappeared. The woman was delivered at 32 weeks and the baby had an uncomplicated postnatal course. We hypothesise that maternal ketoacidosis has been the precipitating factor of tachycardia and congestive heart failure and that this case is conceptually similar to the "late death" phenomenon, reported in cases of poorly controlled maternal diabetes.

Acute renal failure due to rhabdomyolysis in diabetic patients

We report a 32-year-old Black man, admitted to the ICU with coma and severe metabolic disturbances due to diabetic ketoacidosis. During the admission, rhabdomyolysis and acute renal failure (ARF) were diagnosed. After metabolic control and gradual decrease of creatine kinase levels, he presented a progressive improvement of renal function. We emphasize nontraumatic rhabdomyolysis as a poorly recognized pathogenetic factor for ARF in diabetic ketoacidosis and suggest that a better understanding of its mechanisms and an early application of protective measures is necessary.

Motor aphasia due to prolonged hypoglycaemic coma in a patient with insulin-dependent diabetes mellitus

A 45-year-old insulin-dependent diabetic man was in a hypoglycaemic coma for one month but recovered after continuous infusion of glucose and insulin. An isolated neurological deficit, motor aphasia, persisted after recovery from the coma. Repeated computerized tomography did not demonstrate any abnormal findings attributable to coma or aphasia. Precise follow-up examinations of aphasia showed improvement of Broca type motor aphasia to transcortical motor aphasia. Hypoglycaemic aphasia in a patient after recovery from prolonged coma is rare and its clinical course and pathogenesis are discussed with reference to the available literature.

[Intracranial hypertension in severe diabetic ketoacidosis with coma. Two cases]

We observed two cases of severe diabetic ketoacidosis with coma and shock. In one case, coma was present at admission and in the second occurred within 15 hours. In both cases, intracranial hypertension was confirmed with an extradural captor. These findings are in agreement with observations of brain oedema in diabetic ketoacidosis with coma. Clinical data suggest that brain oedema may occur after a latency period but that clinical expression is much more rare, perhaps favoured by treatment (excessive rehydratation, alkalinization, too sharp drop in blood glucose level). In our cases, despite major fluid infusion, shock persisted requiring norepinephrine. This shock could have been the expression of the severe ketoacidosis or have resulted from an underlying infection. In case of sudden onset coma, a regularly encountered manifestation of brain oedema, respiratory assistance and mannitol infusion must be instituted rapidly. With this type of management, it should be possible to improve the severe prognosis of brain oedema in diabetic ketoacidosis.

[Diabetic coma and bases of proper treatment]

Hyperglycaemic, hyperosmolar coma developing in diabetes mellitus-with or without ketoacidosis-is a perilous metabolic catastrophe, preserving its clinical importance even nowadays. The features of the two basic forms of diabetic coma, the development and characteristics of clinical symptoms and laboratory alterations caused by absolute or relative lack of insulin are reported by the author. The importance of early diagnosis and up-to-date intensive treatment is emphasized, regarding the need of decreasing of the still now considerable mortality rate. Fundamental principles of the therapeutic interventions are the following: improvement of the microcirculation through appropriate compensation of fluid and elektrolytes, intravenous or intramuscular administration of low-dose insulin, prevention of hypokalemic condition, and correction of acidosis under pH 7,1 value. Moreover, the well-planned supportive treatment is also essential: prevention of thromboembolism, averting the occasional development of shock caused usually by infections, and prophylaxis of the often fatal cerebral oedema. The estimation and follow-up of osmolality and the prevention of rapid changes in serum glucose and electrolyte levels are of particular importance in every cases. Careful observation of the patients regarding the cardiorespiratory and renal functions is of great significance in both (first and second) phases of the treatment. Improvement of patients' education, controlled care of diabetic patients, reduction of the number of recidive cases and increasing knowledge regarding diabetes among the general practitioners are determined by the author as the future possibilities for the prevention of this severe metabolic disorder.

[Acute endocrinology]

The author presents a practical guide for diagnosis and management of some common emergencies. The most common are hypoglycaemia in persons with diabetes, diabetic ketoacidosis and non-ketotic hyperosmolar diabetic coma. Acute adrenocortical failure is also quite common. These three conditions can be presented in persons with diagnosed disease. Therefore prevention should be possible with proper education. In rare cases the emergency situation is the presenting symptom. Thyreotoxic crisis, myxoedema coma and hypercalcemic crisis are less common. A high level of suspicion is important for early diagnosis and successful treatment of these conditions.

Comparison of intramuscular glucagon and intravenous dextrose in the treatment of hypoglycaemic coma in an accident and emergency department

Hypoglycaemia remains a serious and much feared complication of insulin therapy. In this study, patients attending an accident and emergency department in hypoglycaemic coma were randomized to treatment with either intravenous dextrose (25g) or intramuscular glucagon (1mg), administered into the right thigh. Restoration of normal conscious level was slower after glucagon than dextrose (9.0 vs 3.0 min, P less than 0.01), although the average duration of hypoglycaemic coma was 120 min. Two patients in the glucagon-treated group, who failed to show satisfactory recovery after 15 min, required additional treatment with intravenous dextrose. On questioning following recovery, all except two patients reported loss of awareness of the onset of hypoglycaemia Intramuscular glucagon is valuable in the treatment of severe hypoglycaemia outwith hospital and, although the slightly slower and less predictable recovery may appear to make it a less attractive option than intravenous dextrose in the accident and emergency department, this must be balanced against the advantages of ease of administration and a lower incidence of serious adverse effects.

[Experience with the treatment of diabetic coma]

To investigate the effect of low-dose versus high-dose insulin treatment of Kussmaul's coma, the authors treated 2 groups of relevant patients. Group I treated with low-dose insulin in combination with other therapeutic measures achieved a progressive decrease of glycemia within 8 hours. Complications were not registered. Group II on high-dose insulin scheme exhibited a drop in blood sugar resultant in hypoglycemia in 4, hypotonia in 2, brain edema in 1 patient. The absence of complications, availability and simplicity support the advantages of the low-dose regime which is now widely introduced into clinical practice.

[Low-dose dopamine treatment of patients in nonketotic hyperosmolar hyperglycemic coma]

In the acute neurosurgical setting, nonketotic hyperosmolar hyperglycemic coma (NHC) is thought to be caused by cerebral dehydration therapy and administration of steroids, glycerol, or mannitol. The mortality of this complication is reportedly very high, and is due to acute renal and/or cardiac failure. The authors evaluated the effect of low-dose dopamine (LDD; 1 to 5 micrograms/kg/min) administration in 10 patients with this syndrome. LDD was given to five patients. In these cases, hypovolemia was treated under central venous pressure monitoring with an iso-osmolar hyponatremic lactate solution given in a volume greater than the urine output. After the hypovolemia was corrected, the fluid was administered in a volume equal to the urine output until the serum osmolarity was normalized. In the five patients not given LDD, a large quantity of hypotonic solution was rapidly administered. In all patients treated with LDD, the urinary sodium increased and the urinary output stabilized. Consequently, the excess urea-nitrogen and serum sodium were quite easily washed out. The total net intake volume for the normalization of serum osmolarity was small and the duration of treatment was much shorter than that of patients not treated with LDD. The LDD regimen was not associated with complications, such as aggravation of cerebral edema, renal failure, or cardiac failure. On the other hand, three of the five patients not given LDD died of acute renal and/or cardiac failure without normalization of laboratory data. It is emphasized that this therapy, which results in beta-effect of catecholamine, sodium diuresis, and increased renal blood flow, is a practical means of managing acute neurosurgical cases complicated by NHC.

Diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma

Diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma are two of the most common acute complications of diabetes. The pathophysiologic changes that occur in both disease states represent an extreme example of the super-fasted state. The physiology of the fed and fasted state, evaluation, therapeutic issues, recommendations for therapy, immediate follow up care, and complications of therapy are reviewed for both syndromes.

Nonketotic hyperosmolal diabetic coma in a child: management with low-dose insulin infusion and intracranial pressure monitoring

Nonketotic hyperosmolal diabetic coma, which is rare in children, is associated with a high mortality in both children and adults. We report a case of nonketotic hyperosmolal diabetic coma in a 3 1/2-year-old child, who was successfully managed with low-dose insulin infusion and invasive intracranial pressure monitoring and recovered without sequelae. Despite severely elevated serum glucose (2,660 mg/dL) and osmolality (435 mosm/kg) levels, there was no elevation of intracranial pressure during her treatment. This case illustrates that insulin should be used cautiously and at low dose in this disease, and that intracranial pressure monitoring is of use in the management of such patients. The pathogenesis and clinical features of nonketotic hyperosmolal diabetic coma are briefly reviewed.

[Coma and praecoma diabeticum. Physiopathology, clinical aspects and therapy]

The diabetic coma is characterized by fundamental metabolic changes. Apart from the hyperglycaemia, exsiccosis and the disturbed electrolyte metabolism are considerable factors contributing to the coma. The treatment of diabetic coma puts great demands on the doctors, since the prognosis can only be improved by systematic and correct intervention. A fast filling up of the volume and a specific electrolyte (potassium) substitution are very important. In cases of ketoacidotic diabetic coma the acidosis must be carefully balanced, whereby the "rest-acidosis" up to pH 7.1 can be tolerated. The administration of insulin can only begin, when the volume and electrolyte substitution is guaranteed, otherwise dangerous insulin-induced hypokalaemia is unavoidable. By no means may the first treatment for the insulinisation be carried out ambulatory.

Treatment of diabetic coma in a tropical environment

Fourteen patients admitted to Muhimbili Medical Centre, Dar es Salaam in diabetic coma were treated according to a management plan based on the hourly administration of low doses of soluble insulin. The use of this treatment plan resulted in a significant fall in mortality. Three patients died. While these results are still unsatisfactory, the study has shown that combining the treatment plan with enthusiastic and constant medical and nursing care, the results of treatment of diabetic coma in the tropics can approach those of the developed world. The treatment plan is described in detail, since we believe that it can be used in hospitals with only basic facilities.

[Continuous perfusion of insulin in the treatment of acidoketotic coma in children]

Ketoacidosis is still a frequent complication as far as our diabetic patients are concerned. The insulin regimen during this acute diabetic ketoacidosis was, until October 1981, administered at the start, half intravenously and half intramuscularly, then discontinuously every four hours, subcutaneously, according to the rate of glucose and acetoacetate. Since then, a new method has been used for the treatment of diabetic ketoacidosis providing a continuous perfusion without pumps, of insulin, glucose and electrolytes. The authors describe their experience, using this technique on ten children admitted to hospital because of severe diabetic ketoacidosis. A certain number of parameters and the evolution were studied. The glycemia graph shows a more harmonious and regular normalisation, urinary ketosis disappears within 8 and 24 hours (with an average of 16,22 h). The next step that consists in administering mixed insulin is taken between the 16th and 48th hours (with an average of 25,42 h). Two hypoglycemia have been reported contrary to the statements of other authors. Furthermore, these parameters were compared to those of 10 children submitted to the classical regimen. The authors conclude that a continuous perfusion presents a better method with approximately similar results, and its use is much simpler both for the patient and for the staff.

Optimal insulin delivery in diabetic ketoacidosis (DKA) and hyperglycemic, hyperosmolar nonketotic coma (HHNC)

Both diabetic ketoacidosis (DKA) and hyperglycemic, hyperosmolar nonketotic coma (HHNC) are stressful metabolic occurrences brought about by the orchestration of numerous events. Adequate hydration and replacement of electrolytes, along with physiologic doses of insulin, are treatment objectives for both of these conditions. Additionally, the physician must search for the factors precipitating these events and frequently evaluate the patient's overall condition.

Low-dose insulin treatment of hyperosmolar diabetic coma

The effect of low-dose hourly i.m. injections of insulin has been studied in the treatment of 17 episodes of hyperosmolar non-ketoacidotic diabetic coma compared with 26 episode of hyperosmolar ketoacidosis occurring in patients over 40 years of age. The fall in blood sugar was satisfactory in the majority of episodes of both types of coma and there was no evidence that patients with hyperosmolar non-ketoacidotic coma were more sensitive to insulin. The excess mortality in the non-ketotic group (47%) compared with the ketoacidotic group (16%) was not due to uncontrolled diabetes.

[The use of artificial beta-cells or programmed insulin infusions in the therapy of insulin-dependent diabetes mellitus]

Completing the article 36, 19-26 (1981) of this journal, the indications for feedback-controlled ("closed-loop", artificial B-cell) and for glucose-independent ("open loop") insulin infusions are defined exactly. So far the artificial B-cell can be used as a bedside equipment only. Its application is restricted to a small number of diabetics who are difficult to be treated. In these cases, some improvement of insulin injection therapy can be obtained by means of so-called normoglycaemie intervening days and by the assessment of the "real" need of insulin using an artificial B-cell. Under certain conditions, open-loop insulin infusions seem to be advantageous both as continuous nocturnal basal rate administrations or as automated whole day infusions with the basal rates supplemented by extra doses to cover the meals. This should, however, be confirmed by controlled studies under ambulatory conditions.