Hyperglycemic Crises

Question 1

Diabetic Ketoacidosis (DKA) Diagnosis

Answer 1

• BG > 250 mg/dL
• Ketones (urine and serum, can be recognized as “fruity” breath)
• Abdominal pain
• N/V
• Dehydration
• Anion gap acidosis (arterial pH < 7.35, anion gap > 12)

Question 2

Hyperosmolar Hyperglycemic State (HHS) Diagnosis

Answer 2

• BG > 600 mg/dL, with high serum osmolality > 320 mOsm/L
• Extreme dehydration
• Confusion, delirium
• pH > 7.3, bicarbonate > 15 mEq/L

Question 3

DKA and HHS Treatment Principle

Answer 3

The primary treatment is aggressive fluids (first) and insulin to treat the hyperglycemia.

Question 4

DKA and HHS Treatment Steps

Answer 4

FLUIDS first for all patients
* Start with NS
* When blood glucose reaches 200 mg/dL, change to D5W1/2NS

REGULAR insulin infusion (regular is preferable in IV solutions)
1. 0.1 units/kg bolus, then 0.1 units/kg/hr continuous infusion OR
2. 0.14 units/kg/hr continuous infusion

PREVENT hypokalemia
* Insulin shifts K+ into the cells; the K+ will fall
* Monitor K+ and keep serum level between 4-5 mEq/L

TREAT acidosis if pH < 6.9; acidosis may be corrected by fluids
* Give sodium bicarbonate if needed