Page 1 of 7

1
Hyperglycemic Emergency Management (DKA/HHS ) - Adult
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

PATIENT WORKUP/
PRESENTATION ASSESSMENT

● History and physical

● Basic metabolic panel,
calcium, phosphorus
Patient presenting and magnesium Obtain arterial blood gas 4
with polyuria, every 4 hours Yes ● Initiate Step 1 of 2: DKA
Is serum
polydipsia, nausea/ ● Capillary blood or HHS Hyperglycemia
bicarbonate
vomiting, or glucose every hour INITIATION order set
2 < 15 mEq/L or
abdominal pain ● Urine ketones ● Consult Endocrinology
respiratory rate
with or without ● Ionized calcium
● Capillary blood ● See Page 2 for
> 16 breaths per
history of ● Diagnostic imaging glucose every hour Yes DKA/HHS Management
minute?
Type 1 or 2 as clinically indicated No 5
● Assess the following: Does patient
diabetes mellitus ○ Hydration status have a diagnosis of
Note: Interventions3 for ○ Electrolyte status hyperglycemic
urinary output and ○ Blood glucose emergency6?
serum bicarbonate ○ Acidosis No Continue work up for
○ Calculate anion gap further treatment or
alternative diagnosis
1
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)
2
If urine ketones are positive, send serum beta-hydroxybutyrate, and start treatment pending results
3
Interventions:
● Strict input and output hourly for a total of 4 hours and notify physician if urine output is < 0.5 mL/kg/hour
● Notify physician if serum bicarbonate < 15 mEq/L
4
Notify physician if pH < 7.2
5
Continue to look for the underlying cause of events
6
Diagnostic criteria:
DKA: blood glucose > 250 mg/dL, arterial pH < 7.3, bicarbonate < 15 mEq/L, and moderate ketonuria or ketonemia [Note: Blood glucose may be lower than expected in patients on SGLT-2 inhibitors (e.g., empagliflozin, canagliflozin)]
HHS: blood glucose > 600 mg/dL, arterial pH > 7.3, bicarbonate > 15 mEq/L, and minimal ketonuria and ketonemia

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 03/24/2020
 Page 2 of 7
Hyperglycemic Emergency Management (DKA/HHS) - Adult
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

TREATMENT INTERVENTION
DKA/HHS Corrected sodium Additional fluids of
Management 1 < 147 mEq/L 0.9% sodium chloride
0.9% sodium chloride 1 liter IV Calculate When blood glucose ≤ 250 mg/dL,
Hydration over 1 hour, then initiate continuous corrected change IVF to D5 0.45% sodium
infusion to replete volume status sodium2 Corrected sodium Additional fluids of
chloride to infuse at current rate
≥ 147 mEq/L 0.45% sodium chloride

Replete and recheck potassium per electrolyte Once potassium ≥ 3.3 mEq/L, give regular
Potassium < 3.3 mEq/L replacement4 protocol. If protocol contraindicated or insulin 0.15 units/kg IV bolus5,6 and ● Recheck
not ordered, notify physician. start regular insulin 0.1 units/kg/hour IV potassium
Potassium infusion3,6 and
and electrolytes
initiation Potassium 3.3-5.5 mEq/L Give regular insulin 0.15 units/kg IV bolus5,6 and start regular insulin 0.1 units/kg/hour IV infusion3,6 every 4 hours
of insulin3 ● See
● Notify ICU team Appendix A
● Stop all sources of potassium administration and treat hyperkalemia as clinically indicated for insulin
Potassium > 5.5 mEq/L 5,6
● Give regular insulin 0.15 units/kg IV bolus and start regular insulin 0.1 units/kg/hour IV infusion
3,6
titration
● Repeat serum potassium every 2 hours until < 5.5 mEq/L

> 7.14 No need to give sodium bicarbonate

Consider sodium bicarbonate IV

pH 6.9 - 7.14 Recheck blood gas hourly for pH and bicarbonate until pH reaches ≥ 7.2
(as per ICU team management)

Treat with sodium bicarbonate IV

< 6.9
(as per ICU team management)
1 4
Consider reduction for patients with heart failure, end-stage liver or renal disease, or > 65 years old Refer to the Critical Care Adult PRN Electrolyte Replacement Orders
2 5
Calculation for corrected sodium = 0.016 x (measured glucose – 100) + measured sodium For insulin management with regular insulin bolus: Usual dose 10-15 units for patients 70-100 kg
3 6
Prime all insulin tubing with 25 units of insulin from bag and do not administer via manifold Consider reducing insulin dose for patients with liver dysfunction/failure or renal disease

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 03/24/2020
 Page 3 of 7
Hyperglycemic Emergency Management (DKA/HHS) - Adult
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

INSULIN TITRATION
See long acting insulin
● Decrease insulin infusion rate by half management below
● Notify ICU/EC Team to: Is
○ Initiate Step 2 of 2: DKA or HHS
● Titrate insulin infusion per anion gap ≤ 12 Yes
Appendix B and
(glucose ≤ 250 mg/dL) order set and serum bicarbonate
● Notify Endocrinology
discontinue Step 1 of 2 ≥ 18 mEq/L?
if insulin infusion is stopped
Yes ○ Change IVF to D 5 0.45% sodium
Insulin Is blood glucose chloride to infuse at current rate No
titration 1 ≤ 250 mg/dL?
No
Continue to monitor capillary blood glucose every hour and titrate insulin infusion per Appendix A

LONG ACTING INSULIN MANAGEMENT

Insulin glargine 0.1 units/kg subcutaneously2

Yes

Initiation of ● Notify Endocrinology Is Discontinue insulin

long-acting ● Endocrinology to dose eGFR < 60 mL/minute/1.73 m2 infusion 2 hours after
insulin long-acting insulin or age > 70 years? long-acting insulin
BMI < 30 Insulin glargine 0.15 units/kg subcutaneously2
administration
No
BMI ≥ 30 or
taking more than
eGFR = estimated glomerular filtration rate Insulin glargine 0.2 units/kg subcutaneously2
1 unit/kg/day
1
Prime all insulin tubing with 25 units of insulin from bag and do not administer via manifold insulin at home
2
Consider reducing insulin dose for patients with liver dysfunction/failure

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 03/24/2020
 Page 4 of 7
Hyperglycemic Emergency Management (DKA/HHS) - Adult
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

APPENDIX A: Blood Glucose Monitoring and Insulin Drip Management for Blood Glucose > 250 mg/dL
Glucose Level Intervention Recheck Glucose

● Decreased by < 50 mg/dL or

increased by any amount Double infusion rate 1 hour post change
● And remains > 250 mg/dL

Decreased by 50-100 mg/dL and

Continue current rate 1 hour
remains > 250 mg/dL

● Decrease rate by half

Decreased by > 100 mg/dL and
● Notify Endocrinology, 1 hour post change
remains > 250 mg/dL
if infusion stopped

Once blood glucose is ≤ 250 mg/dL:

● Decrease insulin infusion rate by half and
● Notify ICU/EC Team:
○ Initiate Step 2 of 2: DKA or HHS (Glucose ≤ 250 mg/dL) order set and discontinue Step 1 of 2
○ Change IVF to D 5 0.45% sodium chloride to infuse at current rate
● See Appendix B

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 03/24/2020
 Page 5 of 7
Hyperglycemic Emergency Management (DKA/HHS) - Adult
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
APPENDIX B: Blood Glucose Monitoring and Insulin Drip Titration for Blood Glucose ≤ 250 mg/dL
Note: Check capillary glucose 1 hour after initiating Step 2 insulin infusion and titrate per parameters below.
Glucose Level Intervention Recheck Glucose
Decrease
● Decrease infusion rate by half
> 100 mg/dL 1 hour
at one time ● Recheck capillary glucose in 1 hour
● Stop infusion, give D50 W 25 mL IV push, and notify Endocrinology
< 70 mg/dL 1 hour
● Recheck capillary glucose every hour until glucose is > 180 mg/dL and restart infusion at half the previous rate when glucose > 180 mg/dL on 1 measurement

● Stop infusion, notify Endocrinology

70-90 mg/dL 1 hour
● Recheck capillary glucose every hour until glucose is > 180 mg/dL and restart infusion at half the previous rate when glucose > 180 mg/dL on 1 measurement
● Decrease infusion rate by half of the current rate and recheck capillary glucose in 1 hour
91-120 mg/dL ● If infusion stopped, notify Endocrinology and recheck capillary glucose every hour until glucose is > 180 mg/dL. Restart infusion at half the previous rate 1 hour
when glucose > 180 mg/dL on 1 measurement.
● Decrease infusion rate by 1 unit/hour and recheck capillary glucose in 1 hour
121-140 mg/dL ● If infusion stopped, notify Endocrinology and recheck capillary glucose every hour until glucose is > 180 mg/dL. Restart infusion at half the previous rate 1 hour
when glucose > 180 mg/dL on 1 measurement.
● No change in Insulin infusion rate and recheck capillary glucose in 1 hour. If no change in infusion rate needed for 3 consecutive hours, decrease glucose
monitoring to every 2 hours.
141-180 mg/dL 1 hour
● If infusion stopped, notify Endocrinology and recheck capillary glucose every hour until glucose is > 180 mg/dL. Restart infusion at half the previous rate
when glucose > 180 mg/dL on 1 measurement.
● If glucose increasing, increase infusion rate by 1 unit/hour and recheck capillary glucose in 1 hour
181-200 mg/dL 1 hour
● If glucose decreasing or the same, continue current rate and recheck capillary glucose in 1 hour

● If glucose increasing, increase infusion rate by 1.5 units/hour and recheck capillary glucose in 1 hour
201-250 mg/dL 1 hour
● If glucose decreasing or the same, continue current rate and recheck capillary glucose in 1 hour
● If glucose increasing, increase infusion rate by 2 units/hour and recheck capillary glucose in 1 hour
251-300 mg/dL 1 hour
● If glucose decreasing or the same, continue current rate and recheck capillary glucose in 1 hour
● If glucose increasing, bolus 10 units of regular insulin IV push AND increase infusion rate by 2 units/hour. Recheck capillary glucose in 1 hour.
301-350 mg/dL 1 hour
● If glucose decreasing or the same, continue current rate and recheck capillary glucose in 1 hour

● If glucose increasing, bolus 15 units of regular insulin IV push AND increase infusion rate by 2 units/hour. Recheck capillary glucose in 1 hour.
˃ 350 mg/dL 1 hour
● If glucose decreasing or the same, continue current rate and recheck capillary glucose in 1 hour
Department of Clinical Effectiveness V4
Approved by the Executive Committee of the Medical Staff on 03/24/2020
 Page 6 of 7
Hyperglycemic Emergency Management (DKA/HHS) - Adult
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

SUGGESTED READINGS

De Beer, K., Michael, S., Thacker, M., Wynne, E., Pattni, C., Gomm, M., . . . Ullah, K. (2008). Diabetic ketoacidosis and hyperglycaemic hyperosmolar syndrome–clinical guidelines.
Nursing in Critical Care, 13(1), 5-11. https://doi.org/10.1111/j.1478-5153.2007.00259.x

Kitabchi, A. E., Umpierrez, G. E., Fisher, J. N., Murphy, M. B., & Stentz, F. B. (2008). Thirty years of personal experience in hyperglycemic crises: Diabetic ketoacidosis and
hyperglycemic hyperosmolar state. The Journal of Clinical Endocrinology & Metabolism, 93(5), 1541-1552. https://doi.org/10.1210/jc.2007-2577

Moghissi, E. S., Korytkowski, M. T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I. B., . . . Umpierrez, G. E. (2009). American Association of Clinical Endocrinologists and American
Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care, 32(6), 1119-1131. https://doi.org/10.2337/dc09-9029

Peters, A. L., Buschur, E. O., Buse, J. B., Cohan, P., Diner, J. C., & Hirsch, I. B. (2015). Euglycemic diabetic ketoacidosis: A potential complication of treatment with sodium-glucose
cotransporter 2 inhibition. Diabetes Care, 38, 1687-1693. https://doi.org/10.2337/dc15-0843

Rosenstock, J. & Ferrannini, E. (2015). Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care, 38, 1638-
1642. https://doi.org/0.2337/dc15-1380

Savage, M. W., Dhatariya, K. K., Kilvert, A., Rayman, G., Rees, J. A. E., Courtney, C. H., . . . Hamersley, M. S. (2011). Joint British Diabetes Societies guideline for the management of
diabetic ketoacidosis. Diabetic Medicine, 28(5), 508-515. https://doi.org/10.1111/j.1464-5491.2011.03246.x

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 03/24/2020
 Page 7 of 7
Hyperglycemic Emergency Management (DKA/HHS) - Adult
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

DEVELOPMENT CREDITS

This practice consensus statement is based on majority opinion of the Hyperglycemic Emergency Management work group at the University of Texas MD Anderson Cancer Center for the
patient population. These experts included:

Conor J. Best, MD (Endocrine Neoplasia and HD)Ŧ

Jeffrey Bruno, PharmD (Pharmacy Clinical Programs)
Wendy Garcia, BS♦
Neetha Jawe, MSN, CCRN, CNL, RN (Nursing ICU)
Tami N. Johnson, PharmD (Pharmacy Clinical Programs)
Victor R. Lavis, MD (Endocrine Neoplasia and HD)Ŧ
Egbert Pravinkumar, MD (Critical Care and Respiratory Care)Ŧ
Sonali Thosani, MD (Endocrine Neoplasia and HD)Ŧ
Mary Lou Warren, DNP, RN, CNS-CC♦

Ŧ
Core Development Team
♦
Clinical Effectiveness Development Team

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 03/24/2020