Intended for healthcare professionals

Clinical Review State of the Art Review

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1114 (Published 29 May 2019) Cite this as: BMJ 2019;365:l1114
  1. Esra Karslioglu French, clinical assistant professor of medicine1,
  2. Amy C Donihi, associate professor of pharmacy and therapeutics2,
  3. Mary T Korytkowski, professor of medicine1
  1. 1Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
  2. 2University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
  1. Correspondence to: M Korytkowski mtk7{at}pitt.edu

Abstract

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

Footnotes

  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: EKF did the primary literature review for this manuscript and wrote the sections on the epidemiology and pathophysiology of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS). ACD wrote the sections on acute management of diabetic ketoacidosis and HHS and carefully compared and contrasted published guidelines from the UK and US. MTK guided the writing of the full manuscript and assumed primary responsibility for the sections on clinical presentation, prevention, and complications. All authors reviewed all sections of the manuscript, providing suggestions for included content and references.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

View Full Text