Management of New-Onset Severe Hyperglycemia

Diagnostic Approach

The American Diabetes Association recommends obtaining arterial blood gases to assess pH and determine if diabetic ketoacidosis (DKA) (pH <7.3) or hyperosmolar hyperglycemic state (HHS) (pH >7.3) is present, with a strength of evidence level of A 1, 2
The American Diabetes Association suggests calculating corrected serum sodium by adding 1.6 mEq/L for each 100 mg/dL glucose above 100 mg/dL, with a strength of evidence level of B 1, 3
The American Diabetes Association recommends calculating effective serum osmolality using the formula 2[measured Na (mEq/L)] + glucose (mg/dL)/18, with a strength of evidence level of A 1, 3

The American Diabetes Association recommends aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/h in the first hour to restore intravascular volume and tissue perfusion, with a strength of evidence level of A 1, 4
The American Diabetes Association suggests initiating continuous intravenous regular insulin once hypokalemia is excluded (K⁺ >3.3 mEq/L), with a loading dose of 0.15 units/kg IV bolus and a continuous infusion of 0.1 units/kg/h, with a strength of evidence level of A 1, 2

The American Diabetes Association recommends monitoring blood glucose, serum electrolytes, BUN, creatinine, and effective serum osmolality every 2-4 hours, with a strength of evidence level of A 1, 2, 4
The American Diabetes Association suggests adding potassium to IV fluids if K⁺ <3.3 mEq/L, with a strength of evidence level of A 1, 4

The American Diabetes Association recommends administering subcutaneous basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrent crisis, with a strength of evidence level of A 2