gms | German Medical Science

Background: Diabetes mellitus is one of the most prevalent chronic diseases in German children [1]. Besides severe hypoglycaemia, ketoacidosis is one of the most relevant emergency situations for diabetic patients [1], [2]. Ketoacidosis occurs when insulin supply is insufficient and no or too little insulin is provided [3]. If a patient develops ketoacidosis, blood sugar levels need to be reduced by administering insulin to restore metabolic control. This prevents life-threatening complications such as cerebral edema [1], [4]. However, research concerning the proper use of insulin devices in such an emergency is scarce. In this study, we investigated the practical skills required for insulin administration in case of ketoacidosis in paediatric patients with type I diabetes.

Materials and methods: In a simulated placebo demonstration, we assessed the practical skills necessary for insulin administration in case of ketoacidosis in paediatric patients. Two cohorts were assessed:
(i) using regular insulin treatment via an insulin pump,
(ii) using regular insulin treatment via an insulin pen.

Depending on the age of the patient, the skills were demonstrated either by the parent responsible for drug administration in routine care (patients aged 0–11 years) or by the adolescents themselves (patients aged 12–17).

According to internal and national standards that ensure proper insulin administration, we predefined the following questions to assess an appropriate administration:
Ad (i): How many participants correctly switch from regular insulin pump treatment to insulin pen in the event of ketoacidosis to correct blood sugar levels?
Ad (ii):

1.

How many participants verify the proper function of their insulin pen before the injection?

2.

How many participants remove air from their insulin pen before injection?

3.

How many participants correctly let the pen needle remain in the subcutaneous tissue for at least 10 seconds after injection?

Characteristics: 50 patients and their parents (25 patients aged 0–11 years, 25 patients aged 12–17 years) took part in the demonstration of practical skills to administer insulin appropriately. The median age of the patients was 12.0 years (Q25/Q75 9.3/14.8; min/max 3.0/17.0) with a median time since diagnosis of type I diabetes of 4.0 years (1.5/7.8; 0.1/12.1). 23 (46%) of the patients were regularly treated with an insulin pump and were assigned to cohort (i), while 27 (54%) were regularly treated with an insulin pen and therefore assigned to cohort (ii).

Patients with regular insulin pump [cohort (i)]: One of the 23 participants (4%) followed the standard of switching to an insulin pen to correct their blood sugar level in the event of ketoacidosis.

Patients with regular insulin pen [cohort (ii)]:

1.

15 of the 27 participants (56%) checked the function of the insulin pen before administration.

2.

Air was removed by one of 27 participants (4%).

3.

20 of the 27 participants (74%) removed the insulin pen from their subcutaneous tissue after at least 10 seconds after insulin injection.

Conclusion: We simulated practical insulin administration, as it is needed in the case of ketoacidosis. We found that children and their parents did not follow internal and national standards appropriately and severe administration errors were committed. Due to the reduced or failed insulin intake, it would have been impossible to restore metabolic control if ketoacidosis had actually occurred. This could have been potentially life-threatening for the affected patients.

Notes: Authors Kapellen TM and Bertsche T: equal contribution