Hyperglycemic Crises in Adult PatientsWith DiabetesABBAS E. KITABCHI, PHD, MD

1

GUILLERMO E. UMPIERREZ, MD2

JOHN M. MILES, MD3

JOSEPH N. FISHER, MD1

D iabetic ketoacidosis (DKA) and thehyperosmolar hyperglycemic state(HHS) are the two most serious acute

metabolic complications of diabetes. DKA isresponsible for more than 500,000 hospitaldays per year (1,2) at an estimated annualdirect medical expense and indirect cost of2.4 billion USD (2,3). Table 1 outlines thediagnostic criteria for DKA and HHS. Thetriad of uncontrolled hyperglycemia, meta-bolic acidosis, and increased total body ke-tone concentration characterizes DKA.HHS is characterized by severe hyperglyce-mia, hyperosmolality, and dehydration inthe absence of significant ketoacidosis.These metabolic derangements result fromthe combination of absolute or relativeinsulin deficiency and an increase in coun-terregulatory hormones (glucagon, cat-echolamines, cortisol, and growthhormone). Most patients with DKA haveautoimmune type 1 diabetes; however, pa-tients with type 2 diabetes are also at riskduring the catabolic stress of acute illnesssuch as trauma, surgery, or infections. Thisconsensus statement will outline precipitat-ing factors and recommendations for the di-agnosis, treatment, and prevention of DKAand HHS in adult subjects. It is based on aprevious technical review (4) and more re-cently published peer-reviewed articlessince 2001, which should be consulted forfurther information.

EPIDEMIOLOGY — Recent epide-miological studies indicate that hospital-izations for DKA in the U.S. areincreasing. In the decade from 1996 to2006, there was a 35% increase in thenumber of cases, with a total of 136,510cases with a primary diagnosis of DKA in2006—a rate of increase perhaps more

rapid than the overall increase in the di-agnosis of diabetes (1). Most patients withDKA were between the ages of 18 and 44years (56%) and 45 and 65 years (24%),with only 18% of patients �20 years ofage. Two-thirds of DKA patients wereconsidered to have type 1 diabetes and34% to have type 2 diabetes; 50% werefemale, and 45% were nonwhite. DKA isthe most common cause of death in chil-dren and adolescents with type 1 diabetesand accounts for half of all deaths in dia-betic patients younger than 24 years ofage (5,6). In adult subjects with DKA, theoverall mortality is �1% (1); however, amortality rate �5% has been reported inthe elderly and in patients with concom-itant life-threatening illnesses (7,8).Death in these conditions is rarely due tothe metabolic complications of hypergly-cemia or ketoacidosis but relates to theunderlying precipitating illness (4,9).Mortality attributed to HHS is consider-ably higher than that attributed to DKA,with recent mortality rates of 5–20%(10,11). The prognosis of both conditionsis substantially worsened at the extremesof age in the presence of coma, hypoten-sion, and severe comorbidities (1,4,8,12,13).

PATHOGENESIS — The events lead-ing to hyperglycemia and ketoacidosis aredepicted in Fig. 1 (13). In DKA, reducedeffective insulin concentrations and in-creased concentrations of counterregula-tory hormones (catecholamines, cortisol,glucagon, and growth hormone) lead tohyperglycemia and ketosis. Hyperglyce-mia develops as a result of three pro-cesses: increased gluconeogenesis,accelerated glycogenolysis, and impaired

glucose utilization by peripheral tissues(12–17). This is magnified by transientinsulin resistance due to the hormone im-balance itself as well as the elevated freefatty acid concentrations (4,18). Thecombination of insulin deficiency and in-creased counterregulatory hormones inDKA also leads to the release of free fattyacids into the circulation from adipose tis-sue (lipolysis) and to unrestrained hepaticfatty acid oxidation in the liver to ketonebodies (�-hydroxybutyrate and acetoace-tate) (19), with resulting ketonemia andmetabolic acidosis.

Increasing evidence indicates that thehyperglycemia in patients with hypergly-cemic crises is associated with a severeinflammatory state characterized by an el-evation of proinflammatory cytokines(tumor necrosis factor-� and interleu-kin-�, -6, and -8), C-reactive protein,reactive oxygen species, and lipid peroxi-dation, as well as cardiovascular risk fac-tors, plasminogen activator inhibitor-1and free fatty acids in the absence of ob-vious infection or cardiovascular pathol-ogy (20). All of these parameters return tonear-normal values with insulin therapyand hydration within 24 h. The proco-agulant and inflammatory states may bedue to nonspecific phenomena of stressand may partially explain the associationof hyperglycemic crises with a hypercoag-ulable state (21).

The pathogenesis of HHS is not aswell understood as that of DKA, but agreater degree of dehydration (due to os-motic diuresis) and differences in insulinavailability distinguish it from DKA(4,22). Although relative insulin defi-ciency is clearly present in HHS, endoge-nous insulin secretion (reflected byC-peptide levels) appears to be greaterthan in DKA, where it is negligible (Table2). Insulin levels in HHS are inadequate tofacilitate glucose utilization by insulin-sensitive tissues but adequate to prevent li-polysis and subsequent ketogenesis (12).

PRECIPITATING FACTORS — Themost common precipitating factor in thedevelopment of DKA and HHS is infec-tion (1,4,10). Other precipitating factorsinclude discontinuation of or inadequateinsulin therapy, pancreatitis, myocardialinfarction, cerebrovascular accident, and

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From the 1Division of Endocrinology, Diabetes and Metabolism, the Department of Medicine, the Universityof Tennessee Health Science Center, Memphis, Tennessee; the 2Emory University School of Medicine,Atlanta, Georgia; and 3Mayo Clinic, Rochester, Minnesota.

Corresponding author: Abbas E. Kitabchi, akitabchi@utmem.edu.An American Diabetes Association consensus statement represents the authors’ collective analysis, evalua-

tion, and opinion at the time of publication and does not represent official association opinion.DOI: 10.2337/dc09-9032© 2009 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

R e v i e w s / C o m m e n t a r i e s / A D A S t a t e m e n t sC O N S E N S U S S T A T E M E N T

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drugs (10,13,14). In addition, new-onsettype 1 diabetes or discontinuation of in-sulin in established type 1 diabetes com-monly leads to the development of DKA.In young patients with type 1 diabetes,psychological problems complicated byeating disorders may be a contributingfactor in 20% of recurrent ketoacidosis.Factors that may lead to insulin omissionin younger patients include fear of weightgain with improved metabolic control,fear of hypoglycemia, rebellion againstauthority, and stress of chronic disease.

Before 1993, the use of continuoussubcutaneous insulin infusion deviceshad also been associated with an in-creased frequency of DKA (23); however,with improvement in technology and bet-ter education of patients, the incidence ofDKA appears to have reduced in pump

users. However, additional prospectivestudies are needed to document reduc-tion of DKA incidence with the use of con-tinuous subcutaneous insulin infusiondevices (24).

Underlying medical illness that pro-vokes the release of counterregulatoryhormones or compromises the access towater is likely to result in severe dehydra-tion and HHS. In most patients with HHS,restricted water intake is due to the pa-tient being bedridden and is exacerbatedby the altered thirst response of the el-derly. Because 20% of these patients haveno history of diabetes, delayed recogni-tion of hyperglycemic symptoms mayhave led to severe dehydration. Elderlyindividuals with new-onset diabetes (par-ticularly residents of chronic care facili-ties) or individuals with known diabetes

who become hyperglycemic and are un-aware of it or are unable to take fluidswhen necessary are at risk for HHS(10,25).

Drugs that affect carbohydrate metabo-lism, such as corticosteroids, thiazides,sympathomimetic agents, and pentami-dine, may precipitate the development ofHHS or DKA (4). Recently, a number of casereports indicate that the conventional anti-psychotic as well as atypical antipsychoticdrugs may cause hyperglycemia and evenDKA or HHS (26,27). Possible mechanismsinclude the induction of peripheral insulinresistance and the direct influence on pan-creatic �-cell function by 5-HT1A/2A/2Creceptor antagonism, by inhibitory effectsvia �2-adrenergic receptors, or by toxic ef-fects (28).

An increasing number of DKA caseswithout precipitating cause have been re-ported in children, adolescents, and adultsubjects with type 2 diabetes. Observa-tional and prospective studies indicatethat over half of newly diagnosed adultAfrican American and Hispanic subjectswith unprovoked DKA have type 2 diabe-tes (28–32). The clinical presentation insuch cases is acute (as in classical type 1diabetes); however, after a short period ofinsulin therapy, prolonged remission isoften possible, with eventual cessation ofinsulin treatment and maintenance of gly-cemic control with diet or oral antihyper-glycemic agents. In such patients, clinicaland metabolic features of type 2 diabetesinclude a high rate of obesity, a strongfamily history of diabetes, a measurablepancreatic insulin reserve, a low preva-lence of autoimmune markers of �-celldestruction, and the ability to discontinueinsulin therapy during follow-up (28,31,32). This unique, transient insulin-requiring profile after DKA has been rec-

Figure 1—Pathogenesis of DKA and HHS: stress, infection, or insufficient insulin. FFA, free fattyacid.

Table 1—Diagnostic criteria for DKA and HHS

DKA HHS

Mild (plasma glucose�250 mg/dl)

Moderate (plasma glucose�250 mg/dl)

Severe (plasma glucose�250 mg/dl)

Plasma glucose�600 mg/dl

Arterial pH 7.25–7.30 7.00 to �7.24 �7.00 �7.30Serum bicarbonate (mEq/l) 15–18 10 to �15 �10 �18Urine ketone* Positive Positive Positive SmallSerum ketone* Positive Positive Positive SmallEffective serum osmolality† Variable Variable Variable �320 mOsm/kgAnion gap‡ �10 �12 �12 VariableMental status Alert Alert/drowsy Stupor/coma Stupor/coma

*Nitroprusside reaction method. †Effective serum osmolality: 2�measured Na� (mEq/l)� � glucose (mg/dl)/18. ‡Anion gap: (Na�) � �(Cl� � HCO3� (mEq/l)�.

(Data adapted from ref. 13.)

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1336 DIABETES CARE, VOLUME 32, NUMBER 7, JULY 2009

ognized mainly in blacks and Hispanicsbut has also been reported in NativeAmerican, Asian, and white populations(32). This variant of diabetes has been re-ferred to in the literature as idiopathictype 1 diabetes, atypical diabetes, “Flat-bush diabetes,” type 1.5 diabetes, andmore recently, ketosis-prone type 2 dia-betes. Some experimental work has shed amechanistic light on the pathogenesis ofketosis-prone type 2 diabetes. At presen-tation, they have markedly impaired in-sulin secretion and insulin action, butaggressive management with insulin im-proves insulin secretion and action to lev-els similar to those of patients with type 2diabetes without DKA (28,31,32). Re-cently, it has been reported that the near-normoglycemic remission is associatedwith a greater recovery of basal and stim-ulated insulin secretion and that 10 yearsafter diabetes onset, 40% of patients arestill non–insulin dependent (31). FastingC-peptide levels of �1.0 ng/dl (0.33nmol/l) and stimulated C-peptide levels�1.5 ng/dl (0.5 nmol/l) are predictive oflong-term normoglycemic remission inpatients with a history of DKA (28,32).

DIAGNOSIS

History and physical examinationThe process of HHS usually evolves overseveral days to weeks, whereas the evolu-

tion of the acute DKA episode in type 1diabetes or even in type 2 diabetes tendsto be much shorter. Although the symp-toms of poorly controlled diabetes may bepresent for several days, the metabolic al-terations typical of ketoacidosis usuallyevolve within a short time frame (typically�24 h). Occasionally, the entire symp-tomatic presentation may evolve or de-velop more acutely, and the patient maypresent with DKA with no prior clues orsymptoms. For both DKA and HHS, theclassical clinical picture includes a historyof polyuria, polydipsia, weight loss, vom-iting, dehydration, weakness, and mentalstatus change. Physical findings may in-clude poor skin turgor, Kussmaul respi-rations (in DKA), tachycardia, andhypotension. Mental status can vary fromfull alertness to profound lethargy orcoma, with the latter more frequent inHHS. Focal neurologic signs (hemianopiaand hemiparesis) and seizures (focal orgeneralized) may also be features of HHS(4,10). Although infection is a commonprecipitating factor for both DKA andHHS, patients can be normothermic oreven hypothermic primarily because ofperipheral vasodilation. Severe hypother-mia, if present, is a poor prognostic sign(33). Nausea, vomiting, diffuse abdomi-nal pain are frequent in patients with DKA(�50%) but are uncommon in HHS (33).Caution needs to be taken with patients

who complain of abdominal pain on pre-sentation because the symptoms could beeither a result of the DKA or an indicationof a precipitating cause of DKA, particu-larly in younger patients or in the absenceof severe metabolic acidosis (34,35). Fur-ther evaluation is necessary if this com-plaint does not resolve with resolution ofdehydration and metabolic acidosis.

Laboratory findingsThe diagnostic criteria for DKA and HHSare shown in Table 1. The initial labora-tory evaluation of patients include deter-mination of plasma glucose, blood ureanitrogen, creatinine, electrolytes (withcalculated anion gap), osmolality, serumand urinary ketones, and urinalysis, aswell as initial arterial blood gases and acomplete blood count with a differential.An electrocardiogram, chest X-ray, andurine, sputum, or blood cultures shouldalso be obtained.

The severity of DKA is classified asmild, moderate, or severe based on theseverity of metabolic acidosis (blood pH,bicarbonate, and ketones) and the pres-ence of altered mental status (4). Signifi-cant overlap between DKA and HHS hasbeen reported in more than one-third ofpatients (36). Although most patientswith HHS have an admission pH �7.30and a bicarbonate level �18 mEq/l, mildketonemia may be present (4,10).

Severe hyperglycemia and dehydra-tion with altered mental status in the ab-sence of significant acidosis characterizeHHS, which clinically presents with lessketosis and greater hyperglycemia thanDKA. This may result from a plasma in-sulin concentration (as determined bybaseline and stimulated C-peptide [Table2]) adequate to prevent excessive lipolysisand subsequent ketogenesis but not hy-perglycemia (4).

The key diagnostic feature in DKA isthe elevation in circulating total blood ke-tone concentration. Assessment of aug-mented ketonemia is usually performedby the nitroprusside reaction, which pro-vides a semiquantitative estimation ofacetoacetate and acetone levels. Althoughthe nitroprusside test (both in urine andin serum) is highly sensitive, it can under-estimate the severity of ketoacidosis be-cause this assay does not recognize thepresence of �-hydroxybutyrate, the mainmetabolic product in ketoacidosis (4,12).If available, measurement of serum �-hydroxybutyrate may be useful for diag-nosis (37). Accumulation of ketoacidsresults in an increased anion gap meta-

Table 2—Admission biochemical data in patients with HHS or DKA

HHS DKA

Glucose (mg/dl) 930 83 616 36Na� (mEq/l) 149 3.2 134 1.0K� (mEq/l) 3.9 0.2 4.5 0.13BUN (mg/dl) 61 11 32 3Creatinine (mg/dl) 1.4 0.1 1.1 0.1pH 7.3 0.03 7.12 0.04Bicarbonate (mEq/l) 18 1.1 9.4 1.43-�-hydroxybutyrate (mmol/l) 1.0 0.2 9.1 0.85Total osmolality* 380 5.7 323 2.5IRI (nmol/l) 0.08 0.01 0.07 0.01C-peptide (nmol/l) 1.14 0.1 0.21 0.03Free fatty acids (nmol/l) 1.5 0.19 1.6 0.16Human growth hormone (ng/ml) 1.9 0.2 6.1 1.2Cortisol (ng/ml) 570 49 500 61IRI (nmol/l)† 0.27 0.05 0.09 0.01C-peptide (nmol/l)† 1.75 0.23 0.25 0.05Glucagon (ng/ml) 689 215 580 147Catacholamines (ng/ml) 0.28 0.09 1.78 0.4Growth hormone (ng/ml) 1.1 7.9Gap: anion gap � 12 (mEq/l) 11 17

*According to the formula 2(Na � K) � urea (mmol/l) � glucose (mmol/l). †Values following intravenousadministration of tolbutamide. IRI, immunoreactive insulin. (Adapted from ref. 4.)

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bolic acidosis. The anion gap is calculatedby subtracting the sum of chloride andbicarbonate concentration from the so-dium concentration: [Na � (Cl �HCO3)]. A normal anion gap is between 7and 9 mEq/l and an anion gap �10–12mEq/l indicate the presence of increasedanion gap metabolic acidosis (4).

Hyperglycemia is a key diagnostic cri-terion of DKA; however, a wide range ofplasma glucose can be present on admis-sion. Elegant studies on hepatic glucoseproduction rates have reported ratesranging from normal or near normal (38)to elevated (12,15), possibly contributingto the wide range of plasma glucose levelsin DKA that are independent of the sever-ity of ketoacidosis (37). Approximately10% of the DKA population presents withso-called “euglycemic DKA”— glucoselevels �250 mg/dl (38). This could bedue to a combination of factors, includingexogenous insulin injection en route to thehospital, antecedent food restriction (39,40), and inhibition of gluconeogenesis.

On admission, leukocytosis with cellcounts in the 10,000–15,000 mm3 rangeis the rule in DKA and may not be indic-ative of an infectious process. However,leukocytosis with cell counts �25,000mm3 may designate infection and requirefurther evaluation (41). In ketoacidosis,leukocytosis is attributed to stress andmaybe correlated to elevated levels of cor-tisol and norepinephrine (42). The ad-mission serum sodium is usually lowbecause of the osmotic flux of water fromthe intracellular to the extracellular spacein the presence of hyperglycemia. An in-creased or even normal serum sodiumconcentration in the presence of hyper-glycemia indicates a rather profound de-gree of free water loss. To assess theseverity of sodium and water deficit, se-rum sodium may be corrected by adding1.6 mg/dl to the measured serum sodiumfor each 100 mg/dl of glucose above 100mg/dl (4,12).

Studies on serum osmolality andmental alteration have established a posi-tive linear relationship between osmolal-ity and mental obtundation (9,36). Theoccurrence of stupor or coma in a diabeticpatient in the absence of definitive eleva-tion of effective osmolality (�320 mOsm/kg) demands immediate consideration ofother causes of mental status change. Inthe calculation of effective osmolality, [so-dium ion (mEq/l) � 2 � glucose (mg/dl)/18], the urea concentration is not takeninto account because it is freely permeableand its accumulation does not induce

major changes in intracellular volumeor osmotic gradient across the cellmembrane (4).

Serum potassium concentration maybe elevated because of an extracellularshift of potassium caused by insulin defi-ciency, hypertonicity, and acidemia (43).Patients with low normal or low serumpotassium concentration on admissionhave severe total-body potassium defi-ciency and require careful cardiac moni-toring and more vigorous potassiumreplacement because treatment lowerspotassium further and can provoke car-diac dysrhythmia. Pseudonormoglycemia(44) and pseudohyponatremia (45) mayoccur in DKA in the presence of severechylomicronemia.

The admission serum phosphate levelin patients with DKA, like serum potas-sium, is usually elevated and does not re-flect an actual body deficit that uniformlyexists due to shifts of intracellular phos-phate to the extracellular space (12,46,47). Insulin deficiency, hypertonicity,and increased catabolism all contribute tothe movement of phosphate out of cells.

Hyperamylasemia has been reportedin 21–79% of patients with DKA (48);however, there is little correlation be-tween the presence, degree, or isoenzymetype of hyperamylasemia and the pres-ence of gastrointestinal symptoms (nau-sea, vomiting, and abdominal pain) orpancreatic imaging studies (48). A serumlipase determination may be beneficial inthe differential diagnosis of pancreatitis;however, lipase could also be elevated inDKA in the absence of pancreatitis (48).

Differential diagnosisNot all patients with ketoacidosis haveDKA. Starvation ketosis and alcoholic ke-toacidosis are distinguished by clinicalhistory and by plasma glucose concentra-tions that range from mildly elevated(rarely �200 mg/dl) to hypoglycemia(49). In addition, although alcoholic ke-toacidosis can result in profound acidosis,the serum bicarbonate concentration instarvation ketosis is usually not �18mEq/l. DKA must also be distinguishedfrom other causes of high–anion gap met-abolic acidosis, including lactic acidosis;ingestion of drugs such as salicylate,methanol, ethylene glycol, and paralde-hyde; and acute chronic renal failure (4).Because lactic acidosis is more commonin patients with diabetes than in nondia-betic persons and because elevated lacticacid levels may occur in severely volume-

contracted patients, plasma lactate shouldbe measured on admission.

A clinical history of previous drugabuse should be sought. Measurement ofserum salicylate and blood methanol levelmay be helpful. Ethylene glycol (anti-freeze) is suggested by the presence of cal-cium oxalate and hippurate crystals in theurine. Paraldehyde ingestion is indicatedby its characteristic strong odor on thebreath. Because these intoxicants are low–molecular weight organic compounds,they can produce an osmolar gap in addi-tion to the anion gap acidosis (14). A re-cent report states that active cocaine use isan independent risk factor for recurrentDKA (50).

Recently, one case report has shownthat a patient with diagnosed acromegalymay present with DKA as the primarymanifestation of the disease (51). In addi-tion, an earlier report of pituitary gigan-tism was presented with two episodes ofDKA with complete resolution of diabetesafter pituitary apoplexy (52).

TREATMENT — Successful treatmentof DKA and HHS requires correction ofdehydration, hyperglycemia, and electro-lyte imbalances; identification of comor-bid precipitating events; and above all,frequent patient monitoring. Protocolsfor the management of patients with DKAand HHS are summarized in Fig. 2 (52).

Fluid therapyInitial fluid therapy is directed toward ex-pansion of the intravascular, interstitial,and intracellular volume, all of which arereduced in hyperglycemic crises (53) andrestoration of renal perfusion. In the ab-sence of cardiac compromise, isotonic sa-line (0.9% NaCl) is infused at a rate of15–20 ml � kg body wt�1 � h�1 or 1–1.5 lduring the first hour. Subsequent choicefor fluid replacement depends on hemo-dynamics, the state of hydration, serumelectrolyte levels, and urinary output. Ingeneral, 0.45% NaCl infused at 250–500ml/h is appropriate if the corrected serumsodium is normal or elevated; 0.9% NaClat a similar rate is appropriate if correctedserum sodium is low (Fig. 2). Successfulprogress with fluid replacement is judgedby hemodynamic monitoring (improve-ment in blood pressure), measurement offluid input/output, laboratory values, andclinical examination. Fluid replacementshould correct estimated deficits withinthe first 24 h. In patients with renal orcardiac compromise, monitoring of se-rum osmolality and frequent assessment

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1338 DIABETES CARE, VOLUME 32, NUMBER 7, JULY 2009

of cardiac, renal, and mental status mustbe performed during fluid resuscitation toavoid iatrogenic fluid overload (4,10,15,53). Aggressive rehydration with sub-sequent correction of the hyperosmolarstate has been shown to result in a morerobust response to low-dose insulin ther-apy (54).

During treatment of DKA, hypergly-cemia is corrected faster than ketoacido-sis. The mean duration of treatment untilblood glucose is �250 mg/dl and ketoac-idosis (pH �7.30; bicarbonate �18mmol/l) is corrected is 6 and 12 h, respec-tively (9,55). Once the plasma glucoseis � 200 mg/dl, 5% dextrose should beadded to replacement fluids to allow con-tinued insulin administration until ke-tonemia is controlled while at the sametime avoiding hypoglycemia.

Insulin therapyThe mainstay in the treatment of DKA in-volves the administration of regular insu-

lin via continuous intravenous infusion orby frequent subcutaneous or intramuscu-lar injections (4,56,57). Randomizedcontrolled studies in patients with DKAhave shown that insulin therapy is effec-tive regardless of the route of administra-t ion (47). The administrat ion ofcontinuous intravenous infusion of regu-lar insulin is the preferred route becauseof its short half-life and easy titration andthe delayed onset of action and prolongedhalf-life of subcutaneous regular insulin(36,47,58).

Numerous prospective randomizedstudies have demonstrated that use oflow-dose regular insulin by intravenousinfusion is sufficient for successful recov-ery of patients with DKA. Until recently,treatment algorithms recommended theadministration of an initial intravenousdose of regular insulin (0.1 units/kg) fol-lowed by the infusion of 0.1 units � kg�1 �h�1 insulin (Fig. 2). A recent prospectiverandomized study reported that a bolus

dose of insulin is not necessary if patientsreceive an hourly insulin infusion of 0.14units/kg body wt (equivalent to 10 units/hin a 70-kg patient) (59). In the absence ofan initial bolus, however, doses �0.1units � kg�1 � h�1 resulted in a lower in-sulin concentration, which may not beadequate to suppress hepatic ketone bodyproduction without supplemental dosesof insulin (15).

Low-dose insulin infusion protocolsdecrease plasma glucose concentration ata rate of 50–75 mg � dl�1 � h�1. If plasmaglucose does not decrease by 50–75 mgfrom the initial value in the first hour, theinsulin infusion should be increased ev-ery hour until a steady glucose decline isachieved (Fig. 2). When the plasma glu-cose reaches 200 mg/dl in DKA or 300mg/dl in HHS, it may be possible to de-crease the insulin infusion rate to 0.02–0.05 units � kg�1 � h�1, at which timedextrose may be added to the intravenousfluids (Fig. 2). Thereafter, the rate of in-

Figure 2—Protocol for management of adult patients with DKA or HHS. DKA diagnostic criteria: blood glucose 250 mg/dl, arterial pH 7.3,bicarbonate 15 mEq/l, and moderate ketonuria or ketonemia. HHS diagnostic criteria: serum glucose �600 mg/dl, arterial pH �7.3, serumbicarbonate �15 mEq/l, and minimal ketonuria and ketonemia. †15–20 ml/kg/h; ‡serum Na should be corrected for hyperglycemia (for each 100mg/dl glucose 100 mg/dl, add 1.6 mEq to sodium value for corrected serum value). (Adapted from ref. 13.) Bwt, body weight; IV, intravenous; SC,subcutaneous.

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sulin administration or the concentrationof dextrose may need to be adjusted tomaintain glucose values between 150 and200 mg/dl in DKA or 250 and 300 mg/dlin HHS until they are resolved.

Treatment with subcutaneous rapid-acting insulin analogs (lispro and aspart)has been shown to be an effective alterna-tive to the use of intravenous regular in-sulin in the treatment of DKA. Treatmentof patients with mild and moderate DKAwith subcutaneous rapid-acting insulinanalogs every 1 or 2 h in non–intensivecare unit (ICU) settings has been shownto be as safe and effective as the treatmentwith intravenous regular insulin in theICU (60,61). The rate of decline of bloodglucose concentration and the mean du-ration of treatment until correction of ke-toacidosis were similar among patientstreated with subcutaneous insulin ana-logs every 1 or 2 h or with intravenousregular insulin. However, until thesestudies are confirmed outside the re-search arena, patients with severe DKA,hypotension, anasarca, or associated se-vere critical illness should be managed withintravenous regular insulin in the ICU.

PotassiumDespite total-body potassium depletion,mild-to-moderate hyperkalemia is com-mon in patients with hyperglycemic cri-ses. Insulin therapy, correction ofacidosis, and volume expansion decreaseserum potassium concentration. To pre-vent hypokalemia, potassium replace-ment is initiated after serum levels fallbelow the upper level of normal for theparticular laboratory (5.0 –5.2 mEq/l).The treatment goal is to maintain serumpotassium levels within the normal rangeof 4–5 mEq/l. Generally, 20–30 mEq po-tassium in each liter of infusion fluid issufficient to maintain a serum potassiumconcentration within the normal range.Rarely, DKA patients may present withsignificant hypokalemia. In such cases,potassium replacement should begin withfluid therapy, and insulin treatmentshould be delayed until potassium con-centration is restored to �3.3 mEq/l toavoid life-threatening arrhythmias and re-spiratory muscle weakness (4,13).

Bicarbonate therapyThe use of bicarbonate in DKA is contro-versial (62) because most experts believethat during the treatment, as ketone bod-ies decrease there will be adequate bicar-bonate except in severely acidoticpatients. Severe metabolic acidosis can

lead to impaired myocardial contractility,cerebral vasodilatation and coma, andseveral gastrointestinal complications(63). A prospective randomized study in21 patients failed to show either beneficialor deleterious changes in morbidity ormortality with bicarbonate therapy inDKA patients with an admission arterialpH between 6.9 and 7.1 (64). Nine smallstudies in a total of 434 patients with di-abetic ketoacidosis (217 treated with bi-carbonate and 178 patients without alkalitherapy [62]) support the notion that bi-carbonate therapy for DKA offers no ad-vantage in improving cardiac orneurologic functions or in the rate of re-covery of hyperglycemia and ketoacido-sis. Moreover, several deleterious effectsof bicarbonate therapy have been re-ported, such as increased risk of hypoka-lemia, decreased tissue oxygen uptake(65), cerebral edema (65), and develop-ment of paradoxical central nervous sys-tem acidosis.

No prospective randomized studiesconcerning the use of bicarbonate in DKAwith pH values �6.9 have been reported(66). Because severe acidosis may lead toa numerous adverse vascular effects (63),it is recommended that adult patientswith a pH �6.9 should receive 100 mmolsodium bicarbonate (two ampules) in 400ml sterile water (an isotonic solution)with 20 mEq KCI administered at a rate of200 ml/h for 2 h until the venous pH is�7.0. If the pH is still �7.0 after this isinfused, we recommend repeating infusionevery 2 h until pH reaches �7.0 (Fig. 2).

PhosphateDespite whole-body phosphate deficits inDKA that average 1.0 mmol/kg body wt,serum phosphate is often normal or in-creased at presentation. Phosphate con-centration decreases with insulin therapy.Prospective randomized studies havefailed to show any beneficial effect ofphosphate replacement on the clinicaloutcome in DKA (46,67), and overzeal-ous phosphate therapy can cause severehypocalcemia (46,68). However, to avoidpotential cardiac and skeletal muscleweakness and respiratory depression dueto hypophosphatemia, careful phosphatereplacement may sometimes be indicatedin patients with cardiac dysfunction, ane-mia, or respiratory depression and inthose with serum phosphate concentra-tion �1.0 mg/dl (4,12). When needed,20–30 mEq/l potassium phosphate canbe added to replacement fluids. The max-imal rate of phosphate replacement gen-

erally regarded as safe to treat severehypophosphatemia is 4.5 mmol/h (1.5ml/h of K2 PO4) (69). No studies are avail-able on the use of phosphate in the treat-ment of HHS.

Transition to subcutaneous insulinPatients with DKA and HHS should betreated with continuous intravenousinsulin until the hyperglycemic crisis isresolved. Criteria for resolution ofketoacidosis include a blood glucose�200 mg/dl and two of the following cri-teria: a serum bicarbonate level �15mEq/l, a venous pH �7.3, and a calcu-lated anion gap �12 mEq/l. Resolution ofHHS is associated with normal osmolalityand regain of normal mental status. Whenthis occurs, subcutaneous insulin therapycan be started. To prevent recurrence ofhyperglycemia or ketoacidosis during thetransition period to subcutaneous insulin,it is important to allow an overlap of 1–2h between discontinuation of intravenousinsulin and the administration of subcu-taneous insulin. If the patient is to remainfasting/nothing by mouth, it is preferableto continue the intravenous insulin infu-sion and fluid replacement. Patients withknown diabetes may be given insulin atthe dosage they were receiving before theonset of DKA so long as it was controllingglucose properly. In insulin-naïve pa-tients, a multidose insulin regimenshould be started at a dose of 0.5–0.8units � kg�1 � day�1 (13). Human insulin(NPH and regular) are usually given intwo or three doses per day. More recently,basal-bolus regimens with basal (glargineand detemir) and rapid-acting insulin an-alogs (lispro, aspart, or glulisine) havebeen proposed as a more physiologic in-sulin regimen in patients with type 1 dia-betes. A prospective randomized trialcompared treatment with a basal-bolusregimen, including glargine once dailyand glulisine before meals, with a split-mixed regimen of NPH plus regular insu-lin twice daily following the resolution ofDKA. Transition to subcutaneousglargine and glulisine resulted in similarglycemic control compared with NPHand regular insulin; however, treatmentwith basal bolus was associated with alower rate of hypoglycemic events (15%)than the rate in those treated with NPHand regular insulin (41%) (55).

ComplicationsHypoglycemia and hypokalemia are twocommon complications with overzealoustreatment of DKA with insulin and bicar-

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1340 DIABETES CARE, VOLUME 32, NUMBER 7, JULY 2009

bonate, respectively, but these complica-tions have occurred less often with thelow-dose insulin therapy (4,56,57). Fre-quent blood glucose monitoring (every1–2 h) is mandatory to recognize hypo-glycemia because many patients withDKA who develop hypoglycemia duringtreatment do not experience adrenergicmanifestations of sweating, nervousness,fatigue, hunger, and tachycardia. Hyper-chloremic non–anion gap acidosis, whichis seen during the recovery phase of DKA,is self-limited with few clinical conse-quences (43). This may be caused by lossof ketoanions, which are metabolized tobicarbonate during the evolution of DKAand excess fluid infusion of chloride con-taining fluids during treatment (4).

Cerebral edema, which occurs in�0.3–1.0% of DKA episodes in children,is extremely rare in adult patients duringtreatment of DKA. Cerebral edema is as-sociated with a mortality rate of 20–40%(5) and accounts for 57–87% of all DKAdeaths in children (70,71). Symptomsand signs of cerebral edema are variableand include onset of headache, gradualdeterioration in level of consciousness,seizures, sphincter incontinence, pupil-lary changes, papilledema, bradycardia,elevation in blood pressure, and respira-tory arrest (71). A number of mechanismshave been proposed, which include therole of cerebral ischemia/hypoxia, thegeneration of various inflammatory medi-ators (72), increased cerebral blood flow,disruption of cell membrane ion trans-port, and a rapid shift in extracellular andintracellular fluids resulting in changes inosmolality. Prevention might includeavoidance of excessive hydration andrapid reduction of plasma osmolarity, agradual decrease in serum glucose, andmaintenance of serum glucose between250–300 mg/dl until the patient’s serumosmolality is normalized and mental sta-tus is improved. Manitol infusion and me-chanical ventilation are suggested fortreatment of cerebral edema (73).

PREVENTION — Many cases of DKAand HHS can be prevented by better ac-cess to medical care, proper patient edu-cation, and effective communication witha health care provider during an intercur-rent illness. Paramount in this effort isimproved education regarding sickday management, which includes thefollowing:

1) Early contact with the health careprovider.

2) Emphasizing the importance of in-

sulin during an illness and the reasonsnever to discontinue without contactingthe health care team.

3) Review of blood glucose goals andthe use of supplemental short- or rapid-acting insulin.

4) Having medications available tosuppress a fever and treat an infection.

5) Initiation of an easily digestible liq-uid diet containing carbohydrates and saltwhen nauseated.

6) Education of family members onsick day management and record keepingincluding assessing and documentingtemperature, blood glucose, and urine/blood ketone testing; insulin administra-tion; oral intake; and weight. Similarly,adequate supervision and staff educationin long-term facilities may prevent manyof the admissions for HHS due to dehy-dration among elderly individuals whoare unable to recognize or treat this evolv-ing condition.

The use of home glucose-ketonemeters may allow early recognition of im-pending ketoacidosis, which may help toguide insulin therapy at home and, possi-bly, may prevent hospitalization for DKA.In addition, home blood ketone monitor-ing, which measures �-hydroxybutyratelevels on a fingerstick blood specimen, isnow commercially available (37).

The observation that stopping insulinfor economic reasons is a common pre-cipitant of DKA (74,75) underscores theneed for our health care delivery systemsto address this problem, which is costlyand clinically serious. The rate of insulindiscontinuation and a history of poorcompliance accounts for more than half ofDKA admissions in inner-city and minor-ity populations (9,74,75). Several culturaland socioeconomic barriers, such as lowliteracy rate, limited financial resources,and limited access to health care, in med-ically indigent patients may explain thelack of compliance and why DKA contin-ues to occur in such high rates in inner-city patients. These findings suggest thatthe current mode of providing patient ed-ucation and health care has significantlimitations. Addressing health problemsin the African American and other minor-ity communities requires explicit recogni-tion of the fact that these populations areprobably quite diverse in their behavioralresponses to diabetes (76).

Significant resources are spent on thecost of hospitalization. DKA episodes rep-resent �1 of every 4 USD spent on directmedical care for adult patients with type 1diabetes and 1 of every 2 USD in patients

experiencing multiple episodes (77).Based on an annual average of 135,000hospitalizations for DKA in the U.S., withan average cost of 17,500 USD per pa-tient, the annual hospital cost for patientswith DKA may exceed 2.4 billion USD peryear (3). A recent study (2) reported thatthe cost burden resulting from avoidablehospitalizations due to short-term uncon-trolled diabetes including DKA is sub-stantial (2.8 billion USD). However, thelong-term impact of uncontrolled diabe-tes and its economic burden could bemore significant because it can contributeto various complications. Because mostcases occur in patients with known diabe-tes and with previous DKA, resourcesneed to be redirected toward preventionby funding better access to care and edu-cational programs tailored to individualneeds, including ethnic and personalhealth care beliefs. In addition, resourcesshould be directed toward the educationof primary care providers and school per-sonnel so that they can identify signs andsymptoms of uncontrolled diabetes andso that new-onset diabetes can be diag-nosed at an earlier time. Recent studiessuggest that any type of education for nu-trition has resulted in reduced hospital-ization (78). In fact, the guidelines fordiabetes self-management education weredeveloped by a recent task force to iden-tify ten detailed standards for diabetesself-management education (79).

Acknowledgments— No potential conflicts ofinterest relevant to this article were reported.

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