Canadian Diabetes Association

Clinical Practice Guidelines

Hyperglycemic Emergencies in
Adults
Chapter 15

Jeannette Goguen, Jeremy Gilbert

 Key Points 2013

1. Suspect DKA or HHS in an ill patient with

hyperglycemia (usually) medical emergency
2. DKA = ketoacidosis is prominent
3. HHS = ECFV contraction + hyperosmolarity
4. Rx = FLUIDS, POTASSIUM, INSULIN (DKA)
5. Treat precipitating cause
6. Prevention is critical

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 Hyperglycemic Emergencies

DKA = Diabetic Ketoacidosis

HHS = Hyperosmolar Hyperglycemic State
Common features:
Insulin deficiency hyperglycemia urinary loss of water
and electrolytes
Volume depletion + electrolyte deficiency +
hyperosmolarity
Insulin deficiency (absolute) + glucagon
Ketoacidosis (in DKA)

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 Suspect DKA or HHS in an ILL Patient with
Hyperglycemia (usually)
DKA HHS
Ketoacidosis Minimal acid-base problem
ECFV contraction ECFV contraction
Milder hyperosmolarity Hyperosmolarity
Normal to high glucose Marked hyperglycemia
May haveLOC Marked LOC
Beware hypokalemia Beware hypokalemia
Must use insulin May need insulin
Absolute insulin deficiency + Relative insulin deficiency
glucagon
ECFV = extracellular fluid volume; LOC = level of consciousness

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 Suspect DKA if

pH 7.3
Bicarbonate 15 mmol/L
Anion gap >12 mmol/L
= (sodium + potassium) (chloride + bicarbonate)
Positive serum or urine ketones
Plasma glucose 14 mmol/L (but may be lower)
Precipitating factor

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 Be Aware of Conditions that may make DKA
Diagnosis Difficult
Mixed acid base disorder (eg. vomiting may raise the
bicarbonate)
Pregnancy normal to minimally elevated glucose
levels
Normal AG due to loss of ketones from osmotic
diuresis
Negative serum ketones due to -hydroxybutarate
AG + negative serum ketones = order serum
-hydroxybutarate
Always order both urine and serum ketones

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 Management of DKA in Adults

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 Fluids, Potassium, Acidosis are the Pillars of
Treatment

IV fluids Serum Acidosis

Potassium

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 Replace Fluids with IV 0.9% NaCl until
Euvolemic

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 Once euvolemic, consider plasma Na+ and
glucose to determine IV fluid type

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 Replace Potassium: Hypokalemia is an
avoidable cause of death in DKA

Correct K+ first
THEN
start insulin

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 Management of Acidosis with Insulin

Insulin should
be maintained
until the anion
gap normalizes

Insulin used to
treat the
acidosis, not
the glucose!
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 Identify and Treat the Precipitating Factor

Insulin omission MOST COMMON CAUSE of DKA

New diagnosis of diabetes
Infection / Sepsis
Myocardial infarction
Small rise in troponin may occur without overt ischemia
ECG changes may reflect hyperkalemia
Thyrotoxicosis
Drugs

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 PREVENTION of DKA / HHS

Type 1 diabetes
Education around sick day management
Continuation of insulin even when not eating
Frequent monitoring when ill
Type 2 diabetes
Education around sick day management
Frequent monitoring when ill

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 Recommendation 1

1. In adult patients with DKA, a protocol should be

followed that incorporates the following principles of
treatment [Grade D, Consensus]
a) Fluid resuscitation
b) Avoidance of hypokalemia
c) Insulin administration
d) Avoidance of rapidly falling serum osmolality
e) Search for precipitating cause
(See figure 1)

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 Recommendation 2
2. In adult patients with HHS, a protocol should be
followed that incorporates the following principles of
treatment [Grade D, Consensus]:
a) Fluid resuscitation
b) Avoidance of hypokalemia
c) Avoidance of rapidly falling serum osmolality
d) Search for precipitating cause
e) Possibly insulin to further reduce hyperglycemia
(See figure 1)

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 Recommendation 3 2013

3. Point-of-care capillary beta-hydroxybutyrate, if

available, may be measured in the hospital in
patients with T1DM with capillary glucose >14
mmol/L to screen for DKA and a beta-
hydroybutyrate >1.5 mmol/L warrants further
testing for DKA [Grade C, level 2]

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 Recommendation 4

4. In individuals with DKA, IV 0.9% sodium chloride

should be administered initially at 500 mL/hour for 4
hours, then 250 mL/hour for 4 hours [Grade B, Level 2]
with consideration of a higher initial rate (12 L/hour)
in the presence of shock [Grade D, Consensus]

For persons with HHS, IV fluid administration

should be individualized based on the patients
needs [Grade D, Consensus]

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 Recommendation 5
5. In individuals with DKA, an infusion of short-acting
IV insulin of 0.10 U/kg/hour should be used [Grade B,
Level 2]

The insulin infusion rate should be maintained until

the resolution of ketosis [Grade B, Level 2] as measured
by the normalization of the plasma anion gap [Grade D,
Consensus]

Once the plasma glucose concentration reaches

14.0 mmol/L, IV dextrose should be started to avoid
hypoglycemia [Grade D, Consensus]

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 CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca for professionals

1-800-BANTING (226-8464)

http://diabetes.ca for patients

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