Hyperglycemic crises resident survival guide
For more information about DKA, click here.

# Overview
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life threatening complications of untreated or inadequately treated diabetes mellitus.  HHS is characterized by hyperglycemia, hyperosmolarity and dehydration; whereas DKA is characterized by hyperglycemia, acidosis, and ketosis.

# Causes

## Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Hyperosmolar hyperglycemic state is a life-threatening condition and must be treated as such irrespective of the causes.

## Common Causes
Common causes of hyperosmolar hyperglycemic state (HHS) include:
- Infections:
Pneumonia
Sepsis
Genitourinary tract infections
- Pneumonia
- Sepsis
- Genitourinary tract infections
- Drugs:
Antipsychotic agents  (clozapine, olanzapine, risperidone)
Illicit drugs (cocaine and alcohol)
Corticosteroids
Glucagon
Interferon
Pentamidine
Sympathomimetic agents (albuterol, dopamine, dobutamine, terbutaline, ritodrine, thiazide diuretics)
- Antipsychotic agents  (clozapine, olanzapine, risperidone)
- Illicit drugs (cocaine and alcohol)
- Corticosteroids
- Glucagon
- Interferon
- Pentamidine
- Sympathomimetic agents (albuterol, dopamine, dobutamine, terbutaline, ritodrine, thiazide diuretics)
- Myocardial infarction
- Pancreatitis
- Shock/hypovolemia
- Trauma
- Undiagnosed diabetes mellitus
- Noncompliance to insulin treatment:
Body image issues
Financial problems
Lack of insulin
Psychological factors
Self-neglect
Accidental
Neglect by caregivers
- Body image issues
- Financial problems
- Lack of insulin
- Psychological factors
- Self-neglect
- Accidental
- Neglect by caregivers

# Management
The diagnostic approach and management management of HHS and DKA are based on the ADA guidelines published in 2009.

## General Approach
- The diagnosis of diabetic ketoacidosis is made in the presence of:
Hyperglycemia- Plasma glucose > 250 mg/dL
Anion gap metabolic acidosis- pH < 7.3; Serum bicarbonate < 15 mEq/L
Ketonemia/ Ketonuria
- Hyperglycemia- Plasma glucose > 250 mg/dL
- Anion gap metabolic acidosis- pH < 7.3; Serum bicarbonate < 15 mEq/L
- Ketonemia/ Ketonuria
- Shown below is a table summarizing the diagnosis of Diabetic ketoacidosis according the the American Diabetes Association (ADA) guidelines.  

## Management: IV Fluids

## Management: Insulin

## Management: Potassium

# Do's
- Check labs initially and every 2-4 hours.
- Immediately check urine for ketones with dipstick and send urine to the lab for analysis.
- Initiate IV insulin as soon as the patient arrives and satisfies the diagnostic criteria of DKA.
- Assess the trigger that precipitated DKA and treat the cause.
- In patients with potassium(K) < 3.3 mEq/L, fluids and potassium replacement must be done before initiating insulin therapy, to prevent further hypokalemia.
- Admit the patient to the floor; however, if the pH < 7.0 or the patient is unconscious then admit to ICU.
- Make sure to calculate the corrected sodium level when evaluating the sodium level.  Sodium can be falsely low due to the elevated glucose level; in order to correct for this, add 1.6 mmol/L of Na+ for every 100 mg/dL of glucose > 100 mg/dL.
- Monitor for complications of DKA itself or of the therapy.
- In case the patient has cardiac or renal compromise, monitor serum osmolality and frequently assess the cardiac, renal and mental status.

# Don'ts
- Do not stop IV insulin until DKA has resolved.
- Do not stop IV insulin, even if subcutaneous insulin is administered because it needs time to kick in.
- Do not give insulin if K+ levels are below 3.3 mEq/l because it may further exacerbate the hypokalemia.
- Do not use 0.9% NaCl if corrected Na+ levels > 145 mEq/l, use 0.45% instead.
- Avoid rapid correction of plasma osmolality and serum sodium, to prevent fatal cerebral edema.
- Maximum reduction in plasma osmolality should be 3 mOsmol/kg per hour.
- Do not supplement phosphate excessively, clinical trials have not shown any benefits. Supplement phosphate only if there is an actual deficit.
- DO not use subcutaneous sliding scale insulin in management of hyperglycemia due to diabetes type 1.