Management of

Acute
Disorders
Related to
Severe
Hyperglycemia

Dysserie Krystal Palermo-Rivera and Sheryl Ray B. Yang-Zamora

 1. Treatment goals in hospital setting
2. Difference of Intensive vs Conventional glucose control
3. How to determine Resolution of hyperglycemic crises
4. Management
4a. Fluids
4b. Insulin
4c. Electrolytes
Lecture Outline Computation of corrected sodium
Potassium correction
Bicarbonate correction
Phosphate correction
4d. nutrition therapy
5. transition of care to outpatient
6. Summary
Dingle, H. E., & Slovis, C. (2018). Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome Management. Emergency Medicine, 50(8), 161–171
Loscalzo, J., Fauci, A., Kasper, D., Hauser, S., Longo, D., & Jameson, L. J. (2022). Harrison’s Principles of Internal Medicine, Twenty-First Edition (Vol.1 & Vol.2) (21st ed.). McGraw Hill /
Medical.
Loscalzo, J., Fauci, A., Kasper, D., Hauser, S., Longo, D., & Jameson, L. J. (2022). Harrison’s Principles of Internal Medicine, Twenty-First Edition (Vol.1 & Vol.2) (21st ed.). McGraw Hill /
Medical.
 1.6-mEq reduction in serum
Na for each 100mg/dL rise
in serum glucose

Loscalzo, J., Fauci, A., Kasper, D., Hauser, S., Longo, D., & Jameson, L. J. (2022). Harrison’s Principles of Internal Medicine, Twenty-First Edition (Vol.1 & Vol.2) (21st ed.). McGraw Hill /
Medical.
Aldhaeefi, M., Aldardeer, N. F., Alkhani, N., Alqarni, S. M., Alhammad, A. M., & Alshaya, A.I. (2022). Updates in the Management of Hyperglycemic Crisis. Frontiers in Clinical Diabetes and
Healthcare,
 1. Confirm diagnosis (↑ serum glucose, ↑ serum β-
hydroxybutyrate, metabolic acidosis).

2. Admit to hospital; intensive care setting may be necessary

for frequent monitoring if pH <7, labored respiration, or
impaired level of arousal.
3. Assess the following:

a. Serum electrolytes: Potassium, Sodium,

Magnesium, Chloride, Bicarbonate and phosphate

b. Acid-base status: pH, HCO3, PCO2, β-

hydroxybutyrate

c. Renal Function (Creatinine and urine output)

Loscalzo, J., Fauci, A., Kasper, D., Hauser, S., Longo, D., & Jameson, L. J. (2022). Harrison’s Principles of Internal Medicine, Twenty-First Edition (Vol.1 & Vol.2) (21st ed.). McGraw Hill /
Medical.
FLUID REPLACEMENT
Copyright © 2006 American Diabetes Association. From Diabetes Care Vol 29, 2006; 2018-2022
 CBG: 378
127.1 + 1.6 X (378-100)
100
Corrected Na = 131.5
 FLUID
Replace fluids: 2-3 L of 0.9% saline or lactated Ringer's over
REPLACEMENT
first 1-3 hr (10-20 ml/kg per hour); subsequently, 0.45% saline
at 250-500 mL/h; change to 5% glucose and 0.45% saline or
lactated Ringer's at 150-250 mL/h when blood glucose reaches
250 mg/dL (13.9 mmol/L).

In HHS, 1-3 L of 0.9% Normal saline over the first 2-3 hr

*If the serum Na is >150 meq/L, 0.45% saline should be used
  The fluid resuscitation is similar to
Euglycemic DKA with correction of
DKA dehydration and starts with
balanced crystalloids.
JAMA Network Open. 2020;3(11):e2024596. doi:10.1001/jamanetworkopen.2020.24596
Self WH, Evans CS, Jenkins CA, et al. Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical
Trials. JAMA Netw Open. 2020;3(11):e2024596. Published 2020 Nov 2. doi:10.1001/jamanetworkopen.2020.24596
 INSULIN
INFUSION
Copyright © 2006 American Diabetes Association. From Diabetes Care Vol 29, 2006; 2018-2022
5. Administer short-acting regular insulin: IV (0.1
units/kg), then 0.1 units/kg per hour by continuous IV
infusion; increase two-to threefold if no response by 2-4 h.
If the initial serum potassium is <3.3 mmol/L (3.3 meq/L),
do not administer insulin until the potassium is corrected.
Subcutaneous insulin may be used in uncomplicated, mild-
moderate DKA with close monitoring.
Copyright © 2006 American Diabetes Association. From Diabetes Care Vol 29, 2006; 2018-2022
Copyright © 2006 American Diabetes Association. From Diabetes Care Vol 29, 2006; 2018-2022
Harrison's Principles of Internal Medicine 21st Edition
6. Assess the patient: What precipitated the episode (non-
compliance, infection, trauma, pregnancy, infarction,
cocaine)? Initiate appropriate work-up for precipitating
event (cultures, CXR, ECG, etc.)

7. Measure blood glucose every 1-2 h; measure

electrolytes (especially K+, bicarbonate, phosphate) and
anion gap every 4 h for the first 24 h.

8. Monitor blood pressure, pulse, respirations, mental status,

fluid intake and output every 1-4 h.
 ELECTROLYTES AND
ACID-BASE CORRECTION
9. Replace potassium: 10 meq/h when plasma
potassium is <5.0-5.2 meq/L (or 20-30 meq/L of
infusion fluid), ECG normal, urine flow and normal
creatinine documented; administer 40-80 meq/h
when plasma potassium <3.5 meq/L or if
bicarbonate is given. If initial serum potassium is
>5.2 mmol/L (5.2 meq/L), do not supplement
potassium until it is corrected.
Copyright © 2006 American Diabetes Association. From Diabetes Care Vol 29, 2006; 2018-2022
 10. Bicarbonate supplementation

Harrison's Principles of Internal Medicine 21st Edition

Copyright © 2006 American Diabetes Association. From Diabetes Care Vol 29, 2006; 2018-2022
 10. Phosphate supplementation

Harrison's Principles of Internal Medicine 21st Edition

11. Continue above until patient is stable, glucose goal
is 8.3-11.1 mmol/L (15.-200 mg/dL), and acidosis is
resolved. Insulin infusion may be decreased to 0.02-0.1
units/kg per hour

12. Administer long-acting insulin as soon as the

patient is eating. Allow for a 2 to 4 hour overlap in
insulin infusion and subcutaneous long-acting insulin
injection.
 CRITERIA FOR TRANSITION TO ORAL
INTAKE AND SUBCUTANEOUS INSULIN:

1. Normal sensorium

2. Normal vital signs

3. Ability to tolerate oral intake, with no emesis

4. Serum Na 135-145 mEq/L

5. Resolution of acidosis as reflected by: Serum

pH >7.3, serum bicarbonate >15 mEq/L, normal
anion gap
 The most convenient time to transition to subcutaneous
insulin is before a meal. The IV insulin infusion should
be continued for two to four hours after initiating the
short- or rapid-acting subcutaneous insulin because
abrupt discontinuation of IV insulin acutely reduces
insulin levels and may result in the recurrence of
hyperglycemia and/or ketoacidosis.

Hirsch, Nathan, & Rubinow. (2022). Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment.
UpToDate.
 We typically do not
Basal insulin (NPH, U-100 glargine, administer degludec or U-
or detemir) can be administered 300 glargine as the basal insulin
either (a) at the same time as the first when transitioning from IV
injection of rapid-acting insulin, or insulin due to its very long half-
(b) earlier (for example, the previous life, and subsequently, the time it
evening), along with a decrease in takes to reach steady state (two
the rate of IV insulin infusion. to three days).​

Hirsch, Nathan, & Rubinow. (2022). Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment.
UpToDate.
MEDICAL NUTRITION
THERAPY
 Medical  Medical nutrition therapy is a key component of the
comprehensive management of diabetes and
Nutrition hyperglycemia in the inpatient setting.
Therapy (MNT)  Maintaining adequate nutrition is important for
in Hospitalized glycemic control and to meet adequate caloric demands.

Patients with  Caloric demand in acute illness will differ from that in
the outpatient setting.
Diabetes  Anyone admitted to the hospital with diabetes or
hyperglycemia should be assessed to determine the need
for a modified diet in order to meet caloric demand.
  metabolic need for patients with diabetes is usually
provided by 25 to 35 calories/kg where some
Medical critically ill patients might require less than 15 to 25
Nutrition calories/kg per day.
Therapy (MNT)  A consistent carbohydrate meal-planning system
in Hospitalized might help to facilitate glycemic control and insulin
dosing in the inpatient setting.
Patients with  Most patients will require 1,500-2000 calories per
Diabetes day with 12-15 grams of carbohydrates per meal.
 Ideally, the carbohydrates should come from low
glycemic index foods such as whole grains and
vegetables.
SUMMARY