Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State Management

DKA and HHS patients are best managed in the intensive care unit with the care of a specialist or endocrinologist.  

Intravenous Fluids  

The initial therapy aims to restore renal perfusion and expand intravascular and extravascular volume. Fluid deficits should be corrected within the first 24 hours of treatment.  

Serum sodium should be corrected for hyperglycemia (for each 5.6 mmol/L glucose >5.6 mmol/L, add 1.6 mmol to the sodium value for corrected serum sodium value). Serum osmolality change should not be >3 mOsm/kg H₂O/hr.  

Avoid iatrogenic fluid overload by frequently monitoring cardiac, renal, and mental status.  

In pediatric patients, initial fluid expansion should not be >50 mL/kg over the first 4 hours of treatment. Fluid deficits should be corrected over the 48 hours of treatment.  

Insulin  

Ketonemia usually takes longer to clear than hyperglycemia. One may or may not be aggressive with insulin administration depending on the patient’s hydration.    

If the patient presents with severe hypokalemia, insulin treatment should be delayed until serum potassium concentration is restored to >3.3 mmol/L to avoid respiratory arrest and arrhythmias.  

There should be an overlap of the intravenous insulin and subcutaneous insulin of 1-2 hours to ensure adequate glucose control. An abrupt discontinuation of intravenous insulin with a delayed onset of subcutaneous insulin may result in inadequate glucose control.  

In newly diagnosed diabetics, the initial total insulin dose should be ~0.5-1 U/kg/day given in ≥2 divided doses. Include both short-acting and long-acting insulin and continue until optimal dosing is established.  

Potassium (K)  

Correction of acidosis, volume expansion, and insulin therapy decrease serum potassium concentration. Hypokalemia may be avoided by potassium replacement.  

Bicarbonate  

Studies have failed to show benefits or deleterious changes in morbidity or mortality with bicarbonate use in DKA patients with a pH between 6.9-7.1. Insulin and bicarbonate can lower serum potassium and supplementation may be required.  

Phosphate  

Patients with cardiac dysfunction, anemia, or respiratory depression may benefit from careful phosphate replacement. Hypophosphatemia may cause cardiac and skeletal muscle weakness and respiratory depression.  

Somatostatin  

Though not considered standard therapy, Somatostatin may be added if patients are resistant to conventional diabetic ketoacidosis therapy. It works by decreasing glucagon secretion and inhibiting ketogenesis. 

Patient Education

Proper education, access to medical care, and effective communication should exist between the patient and healthcare provider during illness.  

For sick-day management, the patient should be instructed when to contact a healthcare professional. Education on supplemental short-acting insulin should be given to meet the proper blood glucose goals.  Fever control and infection treatment should also be taught to the patient. An easily digestible liquid diet that has carbohydrates and salts should also be advised.  

Teach the patient to never discontinue insulin unless instructed by a healthcare professional.