1. Fluid Resuscitation

Prompt restoration of intravascular volume is the foundation of DKA and HHS management. Aggressive fluid replacement improves tissue perfusion, lowers circulating counter-regulatory hormones, and enhances the renal clearance of glucose and ketones. Isotonic crystalloids are the agents of choice, working to expand the extracellular fluid compartment, restore cardiac preload, and increase the glomerular filtration rate, which promotes osmotic diuresis.

A. Choice of Isotonic Crystalloid

The debate between 0.9% sodium chloride (normal saline) and balanced crystalloids (e.g., Ringer’s Lactate, Plasma-Lyte) is ongoing. While normal saline is effective, its high chloride content can lead to a non-anion gap hyperchloremic metabolic acidosis, potentially confounding the assessment of DKA resolution. Balanced solutions more closely mimic plasma composition and may mitigate this risk.

B. Dosing, Titration, and Monitoring

Initial fluid administration should be aggressive in the absence of cardiovascular compromise. A typical adult regimen begins with 500–1000 mL/h for the first 2–4 hours. This rate should be reduced to 250–500 mL/h in patients with heart failure, advanced age, or renal impairment to prevent fluid overload. Continuous monitoring of hemodynamics (blood pressure, heart rate), urine output, and acid-base status is crucial. Before switching to hypotonic fluids, it is essential to calculate the corrected sodium to accurately assess the patient’s true sodium and water balance.

Corrected Sodium Formula: Na⁺_corr = Na⁺_meas + 1.6 × ((Glucose [mg/dL] – 100) / 100)

2. Insulin Therapy

Continuous intravenous (IV) insulin infusion is the cornerstone of therapy for hyperglycemic crises. Its primary roles are to suppress hepatic ketogenesis and lipolysis, facilitate cellular glucose uptake, and ultimately close the anion gap. Regular human insulin is the standard of care due to its predictable pharmacokinetics and low cost when administered intravenously.

A. Dosing and Titration Protocol

1. Initiation: Start a continuous IV infusion at 0.1 units/kg/hour. An initial bolus is generally not necessary but may be considered in severe HHS (0.14 units/kg).
2. Titration: The goal is a steady glucose decline of 50–75 mg/dL per hour. If this target is not met, the infusion rate can be increased by 10–20% hourly.
3. Adding Dextrose: When serum glucose reaches approximately 200–250 mg/dL, reduce the insulin infusion rate to 0.05 units/kg/hour and add a dextrose-containing fluid (e.g., D5W or D10W) to the regimen. This prevents hypoglycemia while allowing insulin to continue suppressing ketogenesis. The target glucose range at this stage is 150–200 mg/dL.

B. Transition to Subcutaneous Regimens

Transitioning from IV to subcutaneous insulin is a high-risk step that requires careful coordination. The patient must be clinically stable with resolution of the hyperglycemic crisis (e.g., anion gap closed, bicarbonate ≥15 mEq/L, tolerating oral intake). To prevent rebound hyperglycemia, the first dose of long-acting (basal) subcutaneous insulin should be administered 1–2 hours before discontinuing the IV infusion. The total daily dose (TDD) is typically calculated as 0.5–0.8 units/kg/day, split 50% as basal and 50% as prandial insulin.

3. Electrolyte Management

Hyperglycemic crises cause profound electrolyte disturbances due to osmotic diuresis and intracellular shifts. Proactive and frequent monitoring and replacement are essential to prevent life-threatening complications.

A. Potassium Replacement

Despite a potentially normal or even elevated serum potassium on presentation, all patients have a significant total-body potassium deficit. Insulin therapy will rapidly shift potassium intracellularly, unmasking this deficit. Replacement should begin once serum K⁺ is <5.2 mEq/L, with a target range of 4.0–5.0 mEq/L. Typically, 20–30 mEq of potassium chloride is added to each liter of IV fluid. Infusion rates should not exceed 10–20 mEq/h via a peripheral line.

B. Phosphate Replacement

Hypophosphatemia is common but rarely requires treatment. Replacement is indicated only for severe depletion (<1.0 mg/dL) accompanied by clinical sequelae such as respiratory muscle weakness, hemolysis, or cardiac dysfunction. If needed, a dose of 0.08–0.16 mmol/kg can be infused over 6 hours.

4. Pharmacokinetic/Pharmacodynamic Considerations

Critical illness significantly alters drug handling. In hyperglycemic crises, particularly when complicated by sepsis, the volume of distribution is expanded due to capillary leak and third-spacing of fluid. This can alter the expected response to both fluids and medications.

• Renal Impairment: Kidney dysfunction prolongs the half-life of insulin. In patients with acute kidney injury or chronic kidney disease, consider a 25–50% reduction in the initial insulin infusion rate and monitor glucose levels with increased frequency.
• Renal Replacement Therapy (RRT): Continuous RRT can clear both insulin and electrolytes. Insulin infusion rates may need to be increased by 10–20% to compensate for clearance by the dialysis filter. Frequent monitoring of glucose and electrolytes is mandatory.

5. Adjunctive and Special Populations

Therapeutic plans must be tailored for specific patient groups and presentations.

A. Euglycemic DKA (euDKA)

Often associated with the use of SGLT2 inhibitors, euDKA presents a diagnostic challenge with glucose levels typically <250 mg/dL but with significant metabolic acidosis and ketosis. Management follows standard DKA principles, but with a key modification: dextrose-containing fluids must be started much earlier, often concurrently with the initial insulin infusion, to prevent hypoglycemia. The offending SGLT2 inhibitor must be discontinued immediately.

B. Pregnancy and End-Stage Renal Disease

6. Delivery Systems and Administration Devices

The safe and precise administration of fluids and insulin is paramount. This requires appropriate vascular access and technology.

• IV Access: At least two large-bore (16–18 gauge) peripheral IV lines are recommended to accommodate high fluid rates and separate infusions. Central venous access may be necessary if peripheral access is poor or for high-concentration potassium infusions.
• Infusion Pumps: All fluids and medications should be administered via programmable infusion pumps. “Smart pumps” with dose-error reduction software (DERS) are the standard of care in the ICU, providing critical safety alerts for dosing errors, occlusions, and low reservoirs.
• Subcutaneous Devices: After ICU discharge, insulin pens are commonly used for administering basal-bolus regimens. They offer improved accuracy and convenience over traditional vial-and-syringe methods.

7. Monitoring Plan and Safety

A structured monitoring plan is essential to guide therapeutic adjustments and prevent iatrogenic complications like hypoglycemia, hypokalemia, and cerebral edema.

• Glucose: Hourly point-of-care testing is required during initial insulin titration. Once the patient is stable on a low-dose infusion with dextrose, frequency can be extended to every 2 hours.
• Electrolytes & Venous Blood Gas: Check potassium, bicarbonate, and pH every 2–4 hours initially to guide repletion and assess resolution of acidosis.
• Anion Gap: Monitor the closure of the anion gap (Na⁺ – [Cl⁻ + HCO₃⁻]) as the primary marker of DKA resolution, rather than relying solely on pH or bicarbonate levels.
• Vital Signs: Hourly assessment of hemodynamics, mental status, and fluid intake/output is critical. Continuous cardiac monitoring (telemetry) is indicated for all patients, especially during aggressive potassium replacement.

8. Pharmacoeconomics and Resource Optimization

Effective management of hyperglycemic crises involves balancing the direct costs of therapies with clinical outcomes to optimize resource use. Standardized protocols and order sets are key to this effort, as they streamline care, reduce errors, and can decrease overall length of stay.

• Fluid Costs: While balanced crystalloids cost more per liter than normal saline, they may reduce the duration of insulin infusion and ICU stay by accelerating the resolution of acidosis, potentially leading to overall cost savings.
• Insulin Formulations: In mild-to-moderate DKA, some studies suggest that subcutaneous rapid-acting insulin analogs can be as effective as IV regular insulin, potentially allowing management outside the ICU and reducing costs.
• Level of Care: Timely transition from the ICU to a step-down unit once biochemical targets are met is crucial for freeing up critical care resources. Clear, protocol-driven criteria for this transition are essential.

9. Clinical Algorithms and Decision Trees

Visual algorithms promote consistent, safe, and evidence-based care by providing clear, stepwise guidance for complex therapeutic decisions. They are invaluable tools for training and for ensuring adherence to best practices at the bedside.