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Definition
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Severe, uncontrolled diabetes characterized by hyperglycemia, ketoacidosis and ketonuria
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Severe, uncontrolled diabetes characterized by hyperglycemia, hyperosmolarity and severe dehydration
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| Plasma glucose |
Greater than 250 mg/dL (13.9 mmol/L); often in the 350 to 500 mg/dL (19.4 to 27.8 mmol/L) range and less than 800 mg/dL (44.4 mmol/L) |
Greater than 600 mg/dL (33.3 mmol/L); may exceed 1000 mg/dL (56 mmol/L) |
| Arterial pH |
Less than 7.30 |
Greater than 7.30 |
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Serum bicarbonate
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Less than 18 |
Greater than 18 |
| Urine ketones |
Positive |
Small/None |
| Serum ketones |
Positive |
Small/None |
| Serum ketones by beta hydroxybutyrate assay (normal is less than 0.6 mmol/L) |
Mild: 3-4 mmolL
Moderate: 4-8 mmol/L
Severe: greater than 8 mmol/L |
Less than 0.6 mmol/L |
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Serum osmolality
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Variable |
Greater than 320 mOsm/kg |
| Anion gap |
Greater than 10 |
Variable |
| Mental status |
Drowsy, stupor/coma |
Stupor/coma |
| BUN/Creatinine |
Elevated |
Elevated |
| Onset |
Rapid (Less than 24 hours) |
Slow, over days |
| Affects |
Both type 1 and 2 DM, but occurs most often in type 1
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Both type 1 and 2 DM, but occurs most often in type 2 and elderly
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| Signs & symptom |
- Kussmaul respirations, hyperventilation (rapid, shallow breathing)
- Severe dehydration
- “Fruity”, acetone breath
- Malaise, weakness, fatigue
- Nausea, vomiting, abdominal pain
- Cardiac arrhythmias, tachycardia
- Hypotension
- Mild disorientation
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- Similar signs and symptoms as DKA
- Polyuria, polydipsia, weight loss
- Dehydration
- Tachycardia
- Hypotension
- Mental status changes, lethargy, obtundation, coma
- Fever
- Loss of vision
- Hallucinations
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| Precipitating factors (Hirsch & Emmett, 2022) |
- Infection (i.e., pneumonia or urinary tract infection)
- New-onset type 1 diabetes mellitus
- Insufficient insulin therapy or poor compliance
- Acute major illness (i.e., myocardial infarction, cerebrovascular event, sepsis, pancreatitis)
- Medications: glucocorticoids, higher-dose thiazide diuretics, sympathomimetic agents (i.e., dobutamine and terbutaline), second-generation "atypical" antipsychotic agents, sodium-glucose co-transporter 2 (SGLT2) inhibitors
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| Treatment, as ordered |
- Assess airway, breathing, circulation.
- Adress mental status.
- Correct fluid deficit per prescriber orders based on degree of hypovolemia and serum Na+.
- Replace electrolytes, particularly potassium (K+) until level is between 3.3-5.3 mEq/L.
- Sodium bicarbonate IV for pH less than 6.9).
- Administer regular insulin to reduce glucose level to 150-200 mg/dL per orders and facility policy.
- Identify underlying cause.
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- Assess airway, breathing, circulation
- Adress mental status
- Correct fluid deficit per prescriber orders based on degree of hypovolemia and serum Na+.
- Replace electrolytes (K+) based on adequate renal function.
- Administer regular insulin to reduce glucose level to 250-300 mg/dL (0.1 units/kg bolus followed by continuous IV infusion @ 0.1 units/kg/hour), per orders and facility policy.
- Identify underlying cause.
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| Signs of resolution |
- Blood glucose level less than 200 mg/dL
- Presence of two of the following:
- Serum bicarbonate level 15 mEq/L or higher
- pH greater than 7.3
- Anion gap 12 mEq/L or lower
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- Osmolality is normal
- When mental status is back to baseline, patient may start clear liquid diet and transition to subcutaneous insulin.
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| Potential complications of treatment |
- Fluid overload due to aggressive fluid replacement
- Hypokalemia due to inadequate potassium replacement, or administration of bicarbonate
- Hypoglycemia due to aggressive insulin treatment
- Cerebral edema due to excessive hydration and rapid intracellular fluid shifts
- Preventive strategies involve a gradual rather than rapid correction of fluid and sodium deficits.
- Maintain a slightly elevated serum glucose until the patient is stable.
- Hypoxemia and noncardiogenic pulmonary edema
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| Nursing considerations |
- Monitor blood glucose every hour until stable.
- Monitor hemodynamics, intake/output, electrolytes (Na+, K+, Mg+, PO4), serum osmolality, BUN and creatinine every 2-4 hours until stable, per your facility policy.
- Assess cardiac, renal, and mental status.
- If hypokalemic, delay insulin treatment until serum K+ is greater than 3.3 mEq/L.
- Monitor arterial blood gas (ABG) and serial basic metabolic panel to determine if acidosis is resolving and anion gap is closing.
- For DKA patients, when the ketoacidosis and anion gap have resolved and the patient is able to eat, begin a multiple-dose (basal-bolus), subcutaneous insulin schedule.
- For HHS patients, IV insulin infusion can be tapered and a multiple-dose (basal-bolus), subcutaneous insulin schedule may be started when the serum glucose falls below 250-300 mg/dL (13.9 to 16. mmol/L).
- IV insulin should continue for 2 to 4 hours after the first dose of subcutaneous insulin administration to avoid hyperglycemia.
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