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Three Part Question

In [a nondiabetic adult with an overdose of insulin] does [excision of the injection site vs conservative management] offer [decreased mortality and incidence of hypoglycaemic brain damage]?

Clinical Scenario

A 28 year old diabetic arrives in the department with a blood sugar of 1.4. After 50mls 50% dextrose she is briefly alert enough to tell you she has taken an overdose of 2ml insulatard into her left thigh. There is a raised area of skin suggestive of an injection site. You wonder whether surgical excision will reduce the availability of insulin and so aid her recovery.

Search Strategy

Medline 1966- 9/03 using the OVID interface
[{exp poisoning/ or exp overdose/ or exp suicide/ or exp suicide, attempted/ or poiso$.af. or overdos$.af. or suicid$.af. or (deliberate adj5 self adj5 harm).af. or dsh.af.} AND {insulin.af OR actrapid.af OR humulin.af OR ultratard.af OR mixtard.af} AND {surgery.af OR excis$.af}] LIMIT to human AND English Language

Search Outcome

9 papers found 2 of which were case reports no trials were found

Comment(s)

Two case reports of treatment by excision were found in which excision improved outcome however as there are no controls it is difficult to draw any useful conclusions particularly as failure of this technique will lead to a level of reporting bias. Randomized trials are likely to be difficult given the low frequency of the method and potential difficulty of finding injection site.

Clinical Bottom Line

Clinical judgement/ local guidelines should be followed