Telaah Kritis

Bicarbonate in diabetic ketoacidosis - a

systematic review
Horng Ruey Chua1,

Antoine Schneider1 and

Rinaldo Bellomo1, 2Email author

Annals of Intensive Care20111:23

1. Did the review address a clearly focused question?

Answer: Yes

To investigate potential effects of continuous subcutaneous insulin infusion (CSII) compared with multiple
daily injections (MDI) on glycemic control in children with type 1 diabetes mellitus (T1DM).

2. Did the authors look for the right type of papers?

Answer: Yes

Meta-analysis and systematic review of randomized control studies (RCTs). The electronic databases
MEDLINE, Cochrane Library, and EMBASE were searched through October 2007.

Is it worth continuing?

Answer: Yes

3. Do you think all the important, relevant studies were included?

Answer: Yes

The following electronic databases were systematically searched for relevant studies: MEDLINE
(1966January 2007), the Cochrane Database of Systematic Reviews (issue 4, 2006), and the
Cochrane Controlled Trials Register (issue 4, 2006), EMBASE (1980January 2007). This
search was updated in October 2007. Furthermore, reference lists from original studies and
review articles were identified. No limit was imposed regarding the language of publication, but
certain publication types (i.e., letters to the editor, abstracts, and communications from scientific
meetings minutes of scientific meetings) were excluded. The text-word terms and MeSH
headings used were diabetes, diabetes mellitus type 1, insulin-dependent diabetes, insulin,
continuous subcutaneous infusion, continuous subcutaneous injection, CSII, pump therapy,
intensive insulin therapy, multiple daily injections, MDI, flexible multiple daily insulin, FMDI,
MSI, children, child*, newborn, infant*, teenagers, teenag*, adolescent*.

4. Did the reviewers authors do enough to asses the quality of the included studies?

Answer: Yes

Titles and abstracts identified in accordance with the search strategy described above were
screened independently by two reviewers. All potentially relevant articles were retained, and full
texts of the studies were examined to determine which of them satisfied the inclusion criteria.
Data extraction was carried out independently by all reviewers using standard data extractions.
Only studies published in the form of complete peer-reviewed publications were included. In
addition to the electronic search, we checked out cross-references from the original articles and
reviews. In the case of studies in which results were expressed in figures, but not in numbers, we
contacted the authors for clarification. We contacted multiple authors, and finally, two researches
answered our queries. Data from crossover studies for both periods were combined. As both
arms were separated by a 2-wk run-in (washout) period, carryover as an effect of treatment
during the first period in these two studies was minimized. Discrepancies between the reviewers
were resolved by discussion.

5. If the results of the studies have been combined, was it reasonable to do so?

Answer: Yes

6. What are the overall results of the review?

Six RCTs involving 165 participants with T1DM met our predefined inclusion criteria. Combined data from
all trials showed that the CSII group compared with the MDI group experienced a significant reduction in
the level of glycosylated hemoglobin. The pooled weighted mean difference (WMD) was 0.24% [95%
confidence interval (95% CI) 0.41 to 0.07, p < 0.001] with a fixed model and remained significant in the
random effect model. This effect was reached by slightly decreasing insulin requirement [three RCTs,
n = 74, WMD 0.22 IU/kg/d (95% CI 0.31 to 0.14, p < 0.001)]. No differences in the incidences of
ketoacidosis and severe hypoglycemic events were found.

7. How precise are these results?

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8. Can the results be applied to the local population?

Answer: Yes
9. Were all important outcomes considered?

Answer: Yes

10. Are the benefits worth the harms and cost?

Answer: Yes