What is the management of a hyperglycemic crisis?

Management of Hyperglycemic Crisis

The management of hyperglycemic crisis requires immediate fluid resuscitation, insulin therapy, electrolyte correction, and treatment of precipitating factors to prevent complications and death. 1, 2

Types of Hyperglycemic Crisis

• Diabetic Ketoacidosis (DKA): Characterized by hyperglycemia, ketosis, and metabolic acidosis, most common in type 1 diabetes 1
• Hyperosmolar Hyperglycemic State (HHS): Characterized by severe hyperglycemia, hyperosmolality, and dehydration without significant ketosis, more common in type 2 diabetes 1, 2

Initial Assessment

• Assess vital signs, mental status, and degree of dehydration 1
• Obtain laboratory tests: blood glucose, electrolytes, blood urea nitrogen, creatinine, serum osmolality, arterial blood gases, urinalysis, and ketones 1, 2
• Identify precipitating factors: infection, medication non-compliance, new-onset diabetes, myocardial infarction, stroke, trauma, or medications (corticosteroids) 1, 2

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour 2
• Total body water deficit in HHS is typically 9 liters (approximately 100-200 mL/kg) 2
• After initial resuscitation, adjust fluid choice based on serum sodium, osmolality, and volume status 1
• Correct estimated deficits within the first 24 hours 2

Insulin Therapy

• After initial fluid resuscitation has begun and hypokalemia is excluded, administer an intravenous bolus of regular insulin at 0.15 U/kg body weight 2
• Follow with continuous infusion at 0.1 U/kg/hour 2, 3
• When blood glucose reaches 250-300 mg/dL, add dextrose to IV fluids while continuing insulin infusion at a reduced rate to prevent hypoglycemia 2
• Monitor blood glucose every 1-2 hours until stable 2

Electrolyte Management

• Monitor serum potassium levels every 2-4 hours as insulin therapy can cause hypokalemia 2
• Begin potassium replacement when serum levels fall below 5.2 mEq/L, provided the patient has adequate urine output 2
• Monitor and replace other electrolytes (magnesium, phosphate) as needed 1

Ongoing Monitoring

• Check blood glucose every 1-2 hours until stable 2
• Monitor electrolytes, blood urea nitrogen, creatinine, and osmolality every 2-4 hours 2, 4
• Ensure that induced change in serum osmolality does not exceed 3 mOsm/kg/hr to prevent cerebral edema 2
• Monitor for signs of fluid overload, especially in elderly patients and those with cardiac or renal disease 1

Treatment of Precipitating Factors

• Identify and treat underlying causes such as infection, medication non-compliance, or new-onset diabetes 2
• Infection is the most common precipitating factor in the development of hyperglycemic crisis 4
• Administer appropriate antibiotics if infection is suspected 1

Transition to Subcutaneous Insulin

• Once the patient is stable, alert, and able to eat, transition to subcutaneous insulin 1
• Continue IV insulin for 1-2 hours after the first subcutaneous dose to prevent rebound hyperglycemia 1

Complications to Monitor

• Cerebral edema: A rare but potentially fatal complication, particularly in children and young adults 2, 4
• Hypoglycemia: Can occur with overzealous insulin treatment 1
• Hypokalemia: Due to insulin administration and treatment of acidosis 1
• Hyperchloremic metabolic acidosis: Can develop during treatment due to excessive saline administration 1

Prevention Strategies

• Patient education on sick-day management, including when to contact healthcare providers 1
• Never discontinue insulin during illness 1
• Regular blood glucose monitoring, especially during illness 1
• Early intervention when blood glucose is consistently elevated 1
• Address barriers to medication access and compliance 1

Special Considerations

• In elderly patients: Higher mortality risk, more cautious fluid resuscitation 1
• In patients with renal or cardiac disease: More careful fluid management 1
• In patients taking SGLT2 inhibitors: Be aware of euglycemic DKA risk 2
• In correctional institutions: Identify high-risk patients and ensure access to prompt treatment 1

By following this algorithmic approach to hyperglycemic crisis management, focusing on fluid resuscitation, insulin therapy, electrolyte correction, and treatment of precipitating factors, mortality can be reduced from up to 20% in HHS to less than 5% in experienced centers 1, 5.