9.4.0.0 DKA & Hy­per­os­mo­lar Hy­per­glycemic State

There is con­sid­erable variabil­i­ty in the pre­sentation of DKA and hy­per­os­mo­lar hy­per­glycemic state, rang­ing from eu­g­lycemia or mild hy­per­glycemia and aci­do­sis to se­vere hy­per­glycemia, de­hy­dra­tion, and coma; there­fore, treat­ment in­di­vid­u­alization based on a care­ful clin­i­cal and lab­o­ra­to­ry as­sess­ment is need­ed (73-76).

Man­age­ment goals in­clude restora­tion of cir­cu­la­to­ry vol­ume and tis­sue per­fu­sion, reso­lu­tion of hy­per­glycemia, and cor­rection of elec­trolyte im­bal­ance and ke­to­sis. It is also im­por­tant to treat any cor­rectable un­der­ly­ing cause of DKA such as sepsis.

In crit­i­cal­ly ill and men­tally ob­tund­ed pa­tients with DKA or hy­per­os­mo­lar hy­per­glycemic state, con­tin­u­ous in­tra­ve­nous in­sulin is the stan­dard of care. Suc­cess­ful tran­si­tion of pa­tients from in­tra­ve­nous to sub­cu­ta­neous in­sulin re­quires ad­min­is­tra­tion of basal in­sulin 2–4 h prior to the in­tra­ve­nous in­sulin being stopped to pre­vent re­cur­rence of ketoaci­do­sis and re­bound hy­per­glycemia (76). There is no significant dif­fer­ence in out­comes for in­tra­ve­nous human reg­u­lar in­sulin ver­sus sub­cu­ta­neous rapid-‍acting ana­logs when com­bined with ag­gres­sive fluid man­age­ment for treat­ing mild or mod­er­ate DKA (77). Pa­tients with un­com­pli­cat­ed DKA may some­times be treat­ed with sub­cu­ta­neous in­sulin in the emer­gen­cy de­part­ment or step-‍down units (78), an ap­proach that may be safer and more cost-‍ef­fec­tive than treat­ment with in­tra­ve­nous in­sulin (79). If sub­cu­ta­neous ad­min­is­tra­tion is used, it is im­por­tant to pro­vide ad­e­quate fluid re­place­ment, nurse train­ing, fre­quent bed­side test­ing, in­fec­tion treat­ment if war­rant­ed, and ap­pro­pri­ate fol­low-‍up to avoid recur­rent DKA. Sev­er­al stud­ies have shown that the use of bi­car­bon­ate in pa­tients with DKA made no dif­fer­ence in reso­lu­tion of aci­do­sis or time to dis­charge, and its use is gen­er­ally not rec­om­mend­ed (80). For fur­ther in­for­ma­tion re­gard­ing treat­ment, refer to re­cent in-‍depth re­views (3).