Interactive Guide to Hyperglycemic Crises

Correct Answer: B) Moderate DKA

Rationale: The patient meets all criteria for DKA: Glucose ≥200 mg/dL (350), β-hydroxybutyrate ≥3.0 mmol/L (5.5), and pH <7.3 (7.20) with bicarbonate <18 mmol/L (12). According to the 2024 DKA severity classification:

• pH 7.0-7.25 falls into Moderate DKA.
• Bicarbonate 10 to <15 mmol/L (12) falls into Moderate DKA.
• β-hydroxybutyrate of 5.5 mmol/L is consistent with moderate DKA (typically 3.0-6.0 mmol/L, though can be higher).

Mild DKA has pH >7.25 to <7.30 and Bicarb 15-18. Severe DKA has pH <7.0 and Bicarb <10. She does not meet criteria for HHS due to significant ketosis and acidosis.

Correct Answer: A) Eff Osm: 347 mOsm/kg; Yes, meets HHS criteria.

Rationale: Calculated Effective Serum Osmolality = [2 x Na⁺ (mmol/L)] + [Glucose (mg/dL) / 18]. Eff Osm = (2 x 150) + (850 / 18) = 300 + 47.22 = 347.22 mOsm/kg.

HHS Diagnostic Criteria (2024):

• Hyperglycemia: Glucose ≥600 mg/dL (850 mg/dL - Met)
• Hyperosmolarity: Effective serum osmolality >300 mOsm/kg (347 mOsm/kg - Met) OR Total osmolality >320 mOsm/kg.
• Absence of significant ketonemia: β-hydroxybutyrate <3.0 mmol/L (1.5 mmol/L - Met)
• Absence of significant acidosis: pH ≥7.3 (7.35 - Met) AND Bicarbonate ≥15 mmol/L (20 mmol/L - Met)

The patient meets all four criteria for HHS. Option D is incorrect because a normal pH is part of HHS criteria (absence of acidosis).

Correct Answer: C) 500-1000 mL/hour of isotonic saline or balanced crystalloid

Rationale: The 2024 guidelines recommend for patients with DKA or HHS without cardiac or renal compromise, initial administration of isotonic saline (0.9% NaCl) or balanced crystalloid solutions at a rate of 500-1000 mL/hour during the first 2-4 hours, especially if severe hypovolemia is present. This can also be thought of as 15-20 mL/kg/hour.

• Option A is too slow for severe hypovolemia.
• Option B suggests hypotonic saline (0.45% NaCl) initially, which is not the first choice; isotonic fluids are preferred for initial resuscitation.
• Option D (D5W) is inappropriate for initial resuscitation as it does not effectively expand intravascular volume and would worsen hyperglycemia without insulin. Dextrose is added later when glucose levels fall.

Correct Answer: B) Hold insulin. Administer 10-20 mmol/hour of potassium until K+ is >3.5 mmol/L, then start insulin.

Rationale: The 2024 guidelines state that if initial serum K+ is <3.5 mmol/L (patient's K+ is 3.1 mmol/L), insulin therapy should be HELD. Potassium replacement should be initiated at a rate of 10-20 mmol/hour until the serum K+ rises to >3.5 mmol/L. Once K+ is corrected, insulin therapy can be started. Administering insulin with hypokalemia can drive potassium further into cells, leading to life-threatening arrhythmias.

• Options A and C are incorrect because insulin should be held.
• Option D is incorrect; IV push potassium is dangerous, and insulin should still be held.

Correct Answer: C) Add 5% or 10% dextrose to the IV fluids (e.g., D5W/0.45% NaCl).

Rationale: The 2024 guidelines recommend adding 5% or 10% dextrose to the IV fluids when the plasma glucose reaches <250 mg/dL in both DKA and HHS. The patient's glucose is 230 mg/dL. This allows the insulin infusion to continue (to resolve ketosis and acidosis) without causing hypoglycemia.

• Option A is incorrect because dextrose is needed to prevent hypoglycemia while insulin continues.
• Option B is incorrect as fluid therapy is still essential.
• Option D is incorrect because dextrose is specifically indicated at this glucose level to allow continued insulin therapy.

Correct Answer: B) Blood β-hydroxybutyrate <0.6 mmol/L, AND (Venous pH ≥7.3 OR Bicarbonate ≥18 mmol/L), AND patient able to eat.

Rationale: The 2024 guidelines define DKA resolution as:

• Plasma/capillary β-hydroxybutyrate <0.6 mmol/L
• AND (Venous pH ≥7.3 OR Bicarbonate ≥18 mmol/L)
• AND Patient is able to eat.
• Glucose ideally should also be <200 mg/dL.

Option A is incorrect because anion gap is no longer a primary resolution criterion, and "feeling better" is subjective. Option C is incorrect as urine ketones are not recommended for monitoring resolution, and the other criteria are incomplete. Option D lists some criteria for HHS resolution, not DKA.

Correct Answer: B) Subcutaneous rapid-acting insulin analog (e.g., lispro) 0.1 units/kg every 1 hour or 0.2 units/kg every 2 hours.

Rationale: The 2024 guidelines explicitly recommend that most individuals with uncomplicated mild or moderate DKA can be treated with subcutaneous rapid-acting insulin analogs every 1 to 2 hours, with close nursing supervision, as an alternative to IV insulin infusion. This can often be done outside an ICU setting.

• Option A (NPH) is a long-acting insulin and not suitable for acute DKA management requiring frequent adjustments.
• Option C (SubQ regular insulin) has a slower onset and longer duration than rapid-acting analogs, making it less ideal for the frequent dosing and rapid adjustments needed in DKA protocols that use SubQ insulin. While historically used, rapid-acting analogs are preferred for these protocols.
• Option D is incorrect as the 2024 guidelines support SubQ insulin for select DKA cases.

Correct Answer: A) 0.05 units/kg/hour

Rationale: For HHS without significant ketosis or acidosis, the 2024 guidelines recommend starting a fixed-rate IV insulin infusion at 0.05 units/kg/hour. A higher rate (0.1 units/kg/hr) is used if there are mixed DKA/HHS features (significant ketosis/acidosis). An insulin bolus is generally not recommended for HHS and is optional in DKA only if there's a delay in starting the infusion. Insulin is a key component of HHS management, not just fluids. The goal for glucose reduction in HHS is also more gradual (not >90-120 mg/dL/hr) to prevent rapid shifts in osmolality.

Correct Answer: B) Yes, all criteria for DKA are met.

Rationale: The 2024 DKA diagnostic criteria are:

• Diabetes/Hyperglycemia (D): Glucose ≥200 mg/dL OR prior history of diabetes. This patient has a history of type 1 diabetes, so this criterion is met even with glucose at 180 mg/dL (this is euglycemic DKA).
• Ketosis (K): β-hydroxybutyrate ≥3.0 mmol/L. The patient's value is 6.5 mmol/L (Met).
• Metabolic Acidosis (A): pH <7.3 AND/OR bicarbonate <18 mmol/L. The patient's pH is 7.15 and bicarbonate is 10 mmol/L (Met).

All three criteria are met. SGLT2 inhibitors are a known risk factor for euglycemic DKA. Anion gap is no longer a primary diagnostic criterion. When treating euglycemic DKA, dextrose-containing fluids should be started with insulin from the beginning.

Correct Answer: B) 0.3 - 0.6 units/kg/day (24-48 units)

Rationale: The 2024 guidelines suggest that for estimating TDD when transitioning to subcutaneous insulin, a weight-based calculation can be used, especially for insulin-naive patients. The typical range is 0.3-0.6 units/kg/day. For an 80 kg patient, this would be 24-48 units.

• Option A is too low.
• Option C is too high for an initial estimate in an insulin-naive patient.
• Option D (using only the last few hours of IV insulin) can be one method, but it should be used with caution as glucotoxicity can overestimate needs, and a weight-based approach is also a primary consideration, especially for naive patients. The guidelines suggest considering weight-based, pre-admission regimen, or IV requirements. For a naive patient, weight-based is a good starting point.

The chosen TDD would then be split, typically 40-60% as basal insulin and the remainder as prandial insulin, divided among meals. Remember to overlap subcutaneous basal insulin with the IV infusion by 1-2 hours.