Hyperglycemic crises resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2], Husnain Shaukat, M.D [3]

Hyperglycemic crises Resident Survival Guide Microchapters


Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life threatening complications of untreated or inadequately treated diabetes mellitus. HHS is characterized by hyperglycemia, hyperosmolarity and dehydration; whereas DKA is characterized by hyperglycemia, acidosis, and ketosis.[1]


Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Hyperosmolar hyperglycemic state is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Common causes of hyperosmolar hyperglycemic state (HHS) include:


The diagnostic approach and management management of HHS and DKA are based on the ADA guidelines published in 2009.[1]

General Approach

Characterize the symptoms:

Weight loss
❑ Weakness
❑ Mental status change
Abdominal pain
❑ Vomiting

Examine the patient:

❑ Poor skin turgor
Kussmaul breathing
Hypothermia or hyperthermia

Identify precipitating factors:

Insulin deficiency
Myocardial infarction
❑ New onset DM type 1
❑ Pregnancy
❑ Stress
Order tests:

❑ Serum glucose
❑ Serum & urinary ketones
Plasma osmolality

❑ Urine, sputum, blood cultures (not routine)
Start the management of the following SIMULTANEOUSLY: (Urgent)
(Check the algorithms below for more details)

IV fluids

Check the following every two hours until the patient is stable:
❑ Glucose
❑ Venous pH
Determine the resolution of HHS:

❑ Blood glucose <200 mg/dl, AND
❑ Two of the following criteria:
- Serum bicarbonate level >15 mEq/l
- Venous pH >7.3
- Calculated anion gap12 mEq/l

Determine the resolution of HHS:
❑ Normal osmolality

❑ Regain of normal mental status

MILD (Plasma Glucose > 250mg/dL or 13.88 mmol/L) MODERATE (Plasma Glucose > 250mg/dL or 13.88 mmol/L) SEVERE (Plasma Glucose > 250mg/dL or 13.88 mmol/L)
Arterial pH 7.25 to 7.30 7.00 to < 7.24 < 7.00
Serum bicarbonate 15 to 18 mEq/L 10 to < 15 mEq/L < 10 mEq/L
Urine ketone (Nitroprusside reaction method) Positive Positive Positive
Serum ketone (Nitroprusside reaction method) Positive Positive Positive
Effective serum osmolality Variable Variable Variable
Anion gap > 10 mEq/L (10 mmol/L) > 12 mEq/L (12 mmol/L) > 12 mEq/L (12 mmol/L)
Mental status Alert Alert/drowsy Stupor/coma

Management: IV Fluids

Initial IV fluid
❑ 0.9% NaCl (15-20ml/kg/hour), OR
❑ 1-1.5L during the first hour
Evaluate the hydration status
Severe hypovolemia
Mild hypovolemia
Cardiogenic shock
❑ Hemodynamic monitoring/pressors
Assess the corrected [Na+]
❑ Administer 0.9% NaCl (1.0L/hour)
High or normal [Na+]
❑ Administer 0.45% NaCl (250-500 ml/hour)
depending on the hydration status
Low [Na+]
❑ Administer 0.9% NaCl (250-500 ml/hour)
depending on the hydration status
Hemodynamic monitoring:
Blood pressure
❑ Laboratory results
❑ Input/output of fluids
❑ Clinical status
When serum glucose reaches
200mg/dL in DKA and 300mg/dl in HHS

❑ Change to 5% dextrose with 0.45% NaCl
(150-250 mL/hour)

Management: Insulin

Check K+ before administering insulin
K+<3.3 mEq/L
❑ Hold insulin and give K+ 20-30 mEq/h
until K+>3.3 mEq/L
K+>5.5 mEq/L
❑ Do not give K
❑ Proceed with insulin
Administer initial IV dose of insulin
❑ Continuous IV infusion of 0.14 U/Kg/h, OR
❑ IV bolus of 0.1 U/Kg, then continuous IV
infusion of 0.1 U/Kg/h
Check if serum glucose falls by 10% in the first hour
❑ Administer IV bolus of 0.14 U/Kg,
then continue previous treatment
When serum glucose reaches 250mg/dl in DKA and 300mg/dl in HHS:
❑ Reduce IV regular insulin infusion to 0.02-0.05 U/kg/h, OR
❑ Administer SC rapid acting insulin at 0.1 U/kg every 2 hours
Keep serum glucose between 150-200 mg/dL until
resolution (200-300 mg/dL for HHS)
❑ Check glucose, BUN, electrolytes, creatinine, venous pH every 3-4 hours until stable
Confirm resolution and
assess ability to eat
Inability to eat
Able to eat
❑ Continue IV insulin infusion
and IV fluid replacement
Transfer from IV to SC insulin
❑ Initiate SC multidose insulin
❑ Continue IV insulin 1-2 hours after
SC insulin is initiated
Patient previously on insulin?
❑ Recommence the insulin home dose
Insulin naive patient?
❑ Start at a multidose of 0.5-0.8 U/kg/day

Management: Potassium

❑ Assess K+ level
❑ Establish adequate renal function
(urine output 50 ml/hour)
K+<3.3 mEq/L
K+= 3.3-5.2 mEq/L
K+>5.2 mEq/L
❑ Hold insulin
❑ Administer 20-30 mEq/hour
until K+>3.3 mEq/L
❑ Administer 20-30 mEq/hour in each
liter of IV fluid to keep serum K+
between 4 and 5 mEq/L
❑ Do not give K+
Keep K+= 4-5 mEq/L
❑ Check K+ every 2 hours
until resolution of HHS


  • Check labs initially and every 2-4 hours.
  • Immediately check urine for ketones with dipstick and send urine to the lab for analysis.
  • Initiate IV insulin as soon as the patient arrives and satisfies the diagnostic criteria of DKA.
  • Assess the trigger that precipitated DKA and treat the cause.
  • In patients with potassium(K) < 3.3 mEq/L, fluids and potassium replacement must be done before initiating insulin therapy, to prevent further hypokalemia.
  • Admit the patient to the floor; however, if the pH < 7.0 or the patient is unconscious then admit to ICU.
  • Make sure to calculate the corrected sodium level when evaluating the sodium level. Sodium can be falsely low due to the elevated glucose level; in order to correct for this, add 1.6 mmol/L of Na+ for every 100 mg/dL of glucose > 100 mg/dL.
  • Monitor for complications of DKA itself or of the therapy.
  • In case the patient has cardiac or renal compromise, monitor serum osmolality and frequently assess the cardiac, renal and mental status.



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