What is the initial management of severe hyperglycemia, including Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)?

From the Guidelines

The initial management of severe hyperglycemia, including Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), should prioritize fluid resuscitation to restore circulatory volume and tissue perfusion, as stated in the most recent guidelines 1. The primary goal is to address dehydration, which is a critical component of both DKA and HHNS, caused by osmotic diuresis due to severe hyperglycemia.

• Key aspects of initial management include:
  • Aggressive intravenous fluid resuscitation, typically with 0.9% normal saline at 15-20 mL/kg/hr in the first hour, adjusting based on hemodynamic status.
  • Insulin therapy, usually starting with an IV insulin infusion at 0.1 units/kg/hr after fluid initiation, to correct hyperglycemia and ketoacidosis.
  • Electrolyte replacement, particularly potassium and phosphate, as guided by serum levels and clinical status.
  • Identification and treatment of any underlying causes, such as infections or other acute illnesses. Management should be individualized based on careful clinical and laboratory assessment, considering the variability in presentation of DKA and HHNS, as emphasized in recent standards of care 1.
• Monitoring should include:
  • Hourly glucose checks.
  • Electrolytes every 2-4 hours.
  • Venous pH and anion gap to monitor resolution of acidosis. Transition to subcutaneous insulin can occur when the patient is stable, with glucose levels <200 mg/dL for DKA or <300 mg/dL for HHNS, and metabolic acidosis is resolving, as outlined in the guidelines 1. This approach is supported by the most recent and highest quality evidence, which prioritizes aggressive fluid management and insulin therapy to improve outcomes in patients with severe hyperglycemia, including DKA and HHNS 1.

From the Research

Initial Management of Severe Hyperglycemia

The initial management of severe hyperglycemia, including Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), involves several key steps:

• Aggressive rehydration with intravenous fluids to restore circulating volume and improve perfusion of vital organs 2, 3, 4
• Insulin therapy to reduce blood glucose levels and inhibit ketone production 2, 3, 4
• Electrolyte replacement to correct imbalances and prevent complications such as hypokalemia 2, 3, 4
• Identification and treatment of underlying precipitating events, such as infections or nonadherence to insulin therapy 3, 5

Fluid Management

The choice of intravenous fluid for rehydration in DKA and HHNS is important:

• 0.9% sodium chloride is commonly used as the initial fluid, but some studies suggest that balanced salt solutions like Hartmann's solution may be beneficial in certain cases 6
• The goal is to restore circulating volume and improve perfusion of vital organs, while also correcting electrolyte imbalances and preventing complications such as hypokalemia 2, 3, 4
• The rate and volume of fluid administration should be tailored to the individual patient's needs, with caution in elderly patients or those with cardiovascular disease 4

Insulin Therapy

Insulin therapy is a critical component of the management of DKA and HHNS:

• Regular human insulin is typically used, with a bolus dose followed by a continuous infusion 2
• The goal is to reduce blood glucose levels and inhibit ketone production, while also preventing hypoglycemia and hypokalemia 2, 3, 4
• The rate of insulin infusion may need to be adjusted based on the patient's response to therapy and the presence of underlying precipitating events 2, 3, 4

Monitoring and Prevention of Complications

Close monitoring of the patient's clinical and laboratory status is essential to prevent complications and ensure optimal outcomes:

• Frequent measurement of blood glucose, electrolytes, and venous blood gases is necessary to guide therapy and prevent complications such as hypoglycemia, hypokalemia, and cerebral edema 2, 3, 4
• Identification and treatment of underlying precipitating events, such as infections or nonadherence to insulin therapy, is critical to prevent recurrence of DKA or HHNS 3, 5