Hyperglycemic Crisis

ADA Guidelines for Hyperglycemic Crisis

(Diabetes Care 2004 27(Supp 1):S94)

Table 1—Diagnostic criteria for DKA and HHS

DKA

HHS   Mild Moderate Severe Plasma glucose (mg/dl) >250 >250 >250 >600 Arterial pH 7.25–7.30 7.00–7.24 <7.00 >7.30 Serum bicarbonate (mEq/l) 15–18 10 to <15 <10 >15 Urine ketones* Positive Positive Positive Small Serum ketones* Positive Positive Positive Small Effective serum osmolality (mOsm/kg) Variable Variable Variable >320 Anion gap >10 >12 >12 Variable Alteration in sensoria or mental obtundation Alert Alert/drowsy Stupor/coma Stupor/coma

* Nitroprusside reaction method;

calculation: 2[measured Na (mEq/l)] + glucose (mg/dl)/18;

calculation: (Na+) – (Cl- + HCO3-) (mEq/l). See text for details.

Table 2—Typical total body deficits of water and electrolytes in DKA and HHS*

Total water (l) 6 9 Water (ml/kg) 100 100–200 Na+ (mEq/kg) 7–10 5–13 Cl- (mEq/kg) 3–5 5–15 K+ (mEq/kg) 3–5 4–6 PO4 (mmol/kg) 5–7 3–7 Mg++ (mEq/kg) 1–2 1–2 Ca++ (mEq/kg) 1–2 1–2

* Data are from Ennis et al. (15) and Kreisberg (8);

Per kilogram of body weight.

Figure 1— Protocol for the management of adult patients with DKA. *DKA diagnostic criteria: blood glucose >250 mg/dl, arterial pH <7.3, bicarbonate <15 mEq/l, and moderate ketonuria or ketonemia. Normal ranges vary by lab; check local lab normal ranges for all electrolytes. After history and physical examination, obtain arterial blood gases, complete blood count with differential, urinalysis, blood glucose, blood urea nitrogen (BUN), electrolytes, chemistry profile, and creatinine levels STAT as well as an electrocardiogram. Obtain chest X-ray and cultures as needed. Serum Na should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum sodium value). IM, intramuscular; IV, intravenous; SC subcutaneous.

Table 3—Summary of major recommendations

Recommendations Grading • Initiate insulin therapy according to recommendations in position statement. A • Unless the episode of DKA is mild, regular insulin by continuous intravenous infusion is preferred. B • Assess need for bicarbonate therapy and, if necessary, follow treatment recommendations in position statement: bicarbonate may be beneficial in patients with a pH <6.9; not necessary if pH is >7.0 C • Studies have failed to show any beneficial effect of phosphate replacement on the clinical outcome in DKA. However, to avoid cardiac and skeletal muscle weakness and respiratory depression due to hypophosphatemia, careful phosphate replacement may sometimes be indicated in patients with cardiac dysfunction, anemia, or respiratory depression and in those with serum phosphate concentration <1.0 mg/dl. A • Studies of cerebral edema in DKA are limited in number. Therefore, to avoid the occurrence of cerebral edema, follow the recommendations in the position statement regarding a gradual correction of glucose and osmolality as well as the judicious use of isotonic or hypotonic saline, depending on serum sodium and the hemodynamic status of the patient. C • Initiate fluid replacement therapy based on recommendations in position statement. A