Management of Hyperglycemic Crises in Diabetes

Hyperglycaemic crises encompass two life-threatening emergencies in diabetes: diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS). Both arise from absolute or relative insulin deficiency combined with counter-regulatory hormone excess, triggering hyperglycaemia, dehydration and metabolic disturbances. Clinically, DKA presents with rapid-onset acidosis, ketonaemia and volume depletion, whereas HHS is characterised by profound hyperglycaemia and hyperosmolality without significant ketosis, often in older individuals with type 2 diabetes. Management rests on prompt fluid resuscitation to restore circulatory volume, judicious correction of electrolyte imbalances—especially potassium—and controlled insulin administration via intravenous infusion. Monitoring includes serial measurement of blood glucose, electrolytes, acid–base status and osmolality to guide therapy and avert complications such as cerebral oedema or hypokalaemia. Transition to subcutaneous insulin and education on adherence, sick-day rules and early recognition of warning signs underpin prevention. Variations in regional guidelines reflect differences in diagnostic thresholds, fluid and insulin protocols and use of adjunctive measures such as bicarbonate. A multidisciplinary approach and structured care pathways have proven essential in reducing morbidity and mortality worldwide.

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Management of Hyperglycemic Crises in Diabetes publication trend

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Technical terms

Diabetic ketoacidosis (DKA): acute metabolic emergency marked by hyperglycaemia, elevated ketone bodies and metabolic acidosis due to insulin deficiency and increased lipolysis.

Hyperglycaemic hyperosmolar state (HHS): severe hyperglycaemia and dehydration leading to increased plasma osmolality, with minimal ketone production and less pronounced acidosis.

Plasma osmolality: concentration of solutes in blood, calculated from electrolytes and glucose, critical for assessing dehydration and guiding fluid therapy.

Anion gap: difference between measured cations and anions in plasma, used to quantify the severity of metabolic acidosis and monitor resolution of DKA.

Intravenous insulin infusion: controlled administration of insulin via continuous infusion, the cornerstone of hyperglycaemic crisis management to reduce glucose and suppress ketogenesis.

References

1. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia (2024).
2. Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020. JAMA Network Open (2021).
3. Multicentre analysis of hyperglycaemic hyperosmolar state and diabetic ketoacidosis in type 1 and type 2 diabetes. Acta Diabetologica (2020).