Hyperglycemic Crises

Learning Objectives: Develop a treatment plan for a patient presenting in acute hyperglycemic crisis.

Hyperglycemic crises including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)
are medical emergencies due to metabolic complications of diabetes.

AG = (Na+) – ((Cl-) + (HCO3-))

Osmolality = 2(Na+) + BUN/2.8 + Glucose/18

Presentation

 ______________________
 ______________________: poor skin turgor, tachycardia, hypotension
 ________________________
 DKA specific: ____________________, __________________
 Catabolic symptoms: _____________, _______________, _____________

Causes
 _____________________________
 Undiagnosed diabetes
 Insulin resistance
 Acute illness or infection
 Limited access to fluids: elderly, bedridden
 Medications: ________________, _________________, __________________, _____________
Pathogenesis

Figure from English et al., 2004

Diagnosis and Distinguishing Features

DKA
Normal HHS
Mild Moderate Severe
BG 90-130 >250 >250 >250 >600
Arterial pH 7.35-7.45 7.25-7.3 7-7.24 <7 >7.3
HCO3 22-26 15-18 10 to <15 <10 >18
Urine ketones - + + + -
Serum - + + + -
ketones
Serum 275-299 Variable Variable Variable >320 mOsm/kg
osmolality
Anion gap 7-9 >10 >12 >12 Variable
Mental Status Alert Alert Alert/drowsy Stupor/coma Stupor/coma
Na 135-145 Variable; usually mildly decreased Normal
K+ 3.5-5 Normal or high Normal or low
Creatinine 0.6-1.3 Elevated Elevated
 Treatment Goals

Correct Correct BG (and Maintain pH in

Maintain K+
dehydration Anion Gap in DKA) DKA

**Identify and Address Underlying Cause**

1. Correct Dehydration

Both DKA and HHS are characterized by severe

dehydration.

NS is usually given 1 L or 15-20 ml/kg over the first hour.

Subsequent fluids depends on hydration, hemodynamics,
UOP, electrolytes.

Corrected Na+ = (Na+) + 0.016 * (BG - 100)

Caution in patients at risk for fluid overload:

__________________, _________________

BG usually corrects more quickly than anion gap in DKA.

Figure from Kitabchi et al., 2009

 2. Electrolytes
If insulin is low K+ is likely to be elevated.

Insulin causes K+ to shift _______________.

K+ supplementation is usually added to IVF or given

separately IVPB. For example, NS+20mEq K+ per L for
maintenance fluids

Figure from Kitabchi et al., 2009

3. Correcting Blood Glucose

Regular insulin IV infusion

DKA: BG corrects before anion gap. Do not

discontinue insulin infusion in DKA until the
anion gap is <12 even if BG is normal.

Figure from Kitabchi et al., 2009

 4. Maintaining pH
DKA only

Use of bicarbonate is controversial

Once ketone bodies decrease, bicarbonate is usually adequate for

correction of pH.

No advantages in improving outcomes or rate of recovery.

Figure from Kibatchi et al., 2009

Monitoring:
 _______________, ____________, _____________, _________ every 2-4 hours until stable
 Hemodynamics at least every 2 hours, UOP, I/O

Resolution:
 DKA: BG <200 mg/dL, HCO3 >=15 mEq/L, venous pH >7.3, anion gap <=12 mEq/L.
 HHS: normal mental status, normal osmolality

Transition to Subcutaenous Insulin:

 Previous Insulin Use: Home dose if adequate
 Insulin naïve: __________ units/kg body weight per day divided ____ % basal, _____% prandial.
 Consider insulin drip requirements after stabilization when determining total daily dose
 Give subcutaneous insulin _______________________ discontinuing insulin infusion
Addressing the Cause

 Medication cost: patient assistance programs and insurance navigation

 Infection or underlying illness: sick day plans
 Discontinuation of causative agents
 Facilitating transitions of care

Summary
 DKA and HHS are medical emergencies associated with poor diabetes control, inadequate
insulin, and dehydration.
 Goal of therapy include correcting fluid status, correcting blood glucose, correcting electrolytes,
and correcting anion gap if present.
 The cause of hyperglycemic crisis should be identified and addressed.

Prepared by Maggie Kline, PharmD

mkline4@iuhealth.org
September 15th, 2020

References
English P, Williams G. Hyperglycaemic crises and lactic acidosis in diabetes mellitus. Postgrad Med J.
2004;80(943):253-261. doi:10.1136/pgmj.2002.004291

Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with
diabetes. Diabetes Care. 2009;32(7):1335-1343. doi:10.2337/dc09-9032

Umpierrez G, Korytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state

and hypoglycaemia. Nat Rev Endocrinol. 2016;12(4):222-232. doi:10.1038/nrendo.2016.1