Diabetic Hyperglycemic Emergencies: A Systematic Approach (Pharmacology CME)

Download Digest PDF

Points and Pearls Excerpt

• Both diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are usually triggered by a precipitating cause: infection, infarction, infant on board (pregnancy), dietary indiscretion, and insulin deficiency. (The “five Is.”)
• In DKA, the pH is typically < 7.3, anion gap > 10, serum bicarbonate < 18 mEq/L, and with both elevated urine and serum ketones.
• In HHS there is typically no ketosis and a normal anion gap, but serum osmolality > 320 mOsm/kg.
• In most adult cases of DKA, fluid deficit is estimated to be 3 to 6 L; in HHS, the deficit is 9 to 12 L.
• Provide volume resuscitation before starting insulin therapy, as it will decrease hyperglycemia 35 to 70 mg/dL, even without insulin.

Most Important References

• Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343. (Review article, ADA consensus guidelines)
• Wolfsdorf JI, Glaser N, Agus M, et al. ISPAD Clinical Practice Consensus Guidelines 2018: diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes. 2018;19 Suppl 27:155-177. (ISPAD clinical practice guidelines)
• Goyal N, Miller JB, Sankey SS, et al. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. 2010;38(4):422-427. (Prospective; 157 patients)
• Ma OJ, Rush MD, Godfrey MM, et al. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003;10(8):836-841. (Prospective observational study; 200 patients)