Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Initial fluids: 15–20 mL/kg 0.9% saline first hour; reassess.
- Start insulin infusion when K+ ≥3.3; hold and replete K+ if <3.3.
- Add dextrose when glucose 200–250 mg/dL to continue ketone clearance.
- Replace K+ aggressively; consider phosphate if severe deficit.
- Transition to SC insulin when gap closed and patient eating; address precipitant.
Clinical Synopsis & Reasoning
Hyperglycemia, ketonemia, and anion-gap metabolic acidosis. Start isotonic fluids, initiate insulin with potassium-safe thresholds, add dextrose when glucose ~200–250 mg/dL to continue ketone clearance, and correct electrolytes; search for triggers.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Glucose, BMP, venous blood gas | Diagnosis/severity | Hyperglycemia, low HCO3-, low pH | Track gap closure |
| Ketones (β-hydroxybutyrate) | Diagnosis | Elevated | Trend with therapy |
| Electrolytes including phosphate and magnesium | Complication prevention | Derangements common | Replace as indicated |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| 0.9% Saline → 0.45% based on Na+ | Crystalloid | Immediate | Restore volume | Avoid rapid osmolality shifts |
| Regular insulin infusion 0.1 U/kg/h | Insulin | Minutes | Clear ketones and close gap | Start when K+ ≥3.3; add dextrose at 200–250 mg/dL |
| Potassium chloride | Electrolyte | Immediate | Maintain K+ 4.0–5.0 mEq/L | Frequent monitoring |
| Phosphate (selected) | Electrolyte | Hours | If severe hypophosphatemia or respiratory weakness | Avoid hypocalcemia |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- International Consensus on Hyperglycemic Crises in Adults (2024) — Link