Hyperglycemic crises in adults: A look at the 2024 consensus report

Paloma Rodriguez Alvarez; Vicente T. San Martin; Oscar L. Morey-Vargas

doi:10.3949/ccjm.92a.24089

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TABLE 1

2024 consensus report criteria for resolution of diabetic ketoacidosis and hyperglycemic hyperosmolar state

Resolution criteria⁵
Diabetic ketoacidosis	Hyperglycemic hyperosmolar state
Plasma or capillary beta-hydroxybutyrate < 0.6 mmol/L AND Venous pH ≥ 7.3 OR Bicarbonate ≥ 18 mmol/L	Serum osmolality < 300 mOsm/kg AND Blood glucose < 250 mg/dL AND Urine output > 0.5 mL/kg/hour AND Cognitive status improved

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TABLE 2

Changes in diabetic ketoacidosis diagnostic criteria between 2009 consensus statement and 2024 consensus report

Diagnostic criteria	2009 Consensus statement⁴	2024 Consensus report⁵
Plasma glucose (D criterion)	Glucose > 250 mg/dL	Glucose ≥ 200 mg/dL OR History of diabetes, irrespective of the presenting glucose value
Ketosis (K criterion)	Serum ketones: positive Urine ketones: positive	Beta-hydroxybutyrate ≥ 3 mmol/L OR Urine ketone strip ≥ 2+
Metabolic acidosis (A criterion)	pH ≤ 7.3 Bicarbonate ≤ 18 mmol/L Anion gap > 10	pH < 7.3 with or without bicarbonate < 18 mmol/L Anion gap was removed as a diagnostic criterion

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TABLE 3

Changes in hyperglycemic hyperosmotic state diagnostic criteria between 2009 consensus statement and 2024 consensus report

Diagnostic criteria	2009 Consensus statement⁴	2024 Consensus report⁵
Hyperglycemia	Plasma glucose > 600 mg/dL	Plasma glucose ≥ 600 mg/dL
Hyperosmolality	Calculated effective serum osmolality > 320 mOsm/kg	Calculated osmolality: Effective^{^a} > 300 mOsm/kg OR Total^{^b} > 320 mOsm/kg
Absence of significant ketosis	Serum ketones: Small Urine ketones: Small	Beta-hydroxybutyrate < 3 mmol/L OR Urine ketones < 2+
Absence of significant acidosis	pH > 7.3 Bicarbonate > 18 mmol/L	pH ≥ 7.3 AND Bicarbonate ≥ 15 mmol/L
Mental status	Stupor or coma	Removed as a diagnostic criterion

↵^aEffective osmolality calculated as 2[sodium (mmol/L)] + glucose (mmol/L)
↵^bTotal osmolality calculated as 2[sodium (mmol/L)] + glucose (mmol/L) + urea (mmol/L)

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TABLE 4

Main changes in treatment recommendations between 2009 consensus statement and 2024 consensus report

		2009 Consensus statement⁴	2024 Consensus report⁵
Fluids	Type	Isotonic saline (0.9% NaCl) during the first hour Subsequently, use 0.45% NaCl if serum sodium is high or normal; continue 0.9% NaCl if serum sodium is low Change to dextrose 5% with 0.45% NaCl when glucose reaches 200 mg/dL in DKA and 300 mg/dL in HHS	Isotonic saline or balanced crystalloid solutions, with subsequent choice of fluids depending on fluid balance, hemodynamics, and sodium concentration 0.45% NaCl is indicated only if osmolality is not declining in HHS despite adequate fluid and insulin therapy Add dextrose 5% or 10% when glucose reaches < 250 mg/dL for both DKA and HHS
	Volume	15–20 mL/kg/hour or 1–1.5 L in the first hour Subsequently, 250–500 mL/hour	500–1,000 mL/hour during the first 2–4 hours Subsequently, adjust rate as clinically appropriate
	Time to correction of estimated fluid deficit	24 hours	24–48 hours (replace 50% of fluid deficit in the first 8–12 hours)
Insulin	Initial	Both DKA and HHS: 0.1 units/kg in IV bolus, followed by FRIII at 0.1 units/kg/hour OR FRIII at 0.14 units/kg/hour	Moderate and severe DKA: FRIII at 0.1 units/kg/hour (consider 0.1 units/kg IV bolus if IV access is delayed) OR Nurse-driven insulin infusion protocol Mild and moderate DKA: Subcutaneous rapid-acting insulin analogue 0.1 units/kg every 1 hour or 0.2 units/kg every 2 hours HHS: FRIII at 0.05 units/kg/hour Mixed DKA/HHS: treat as DKA
	Initial glucose goal for dextrose initiation	DKA: < 200 mg/dL HHS: < 300 mg/dL	DKA and HHS: < 250 mg/dL
	Maintenance after dextrose initiation	Decrease infusion to 0.02–0.05 units/kg/hour until resolution	Decrease infusion to 0.05 units/kg/hour until resolution
	Glucose goal until resolution	DKA: 150–200 mg/dL HHS: 200–300 mg/dL	DKA: 150–200 mg/dL HHS: 200–250 mg/dL
Potassium	Low	< 3.3 mmol/L: give 20–30 mmol/hour and postpone insulin therapy until serum potassium > 3.3 mmol/L	< 3.5 mmol/L: give 10–20 mmol/hour and postpone insulin therapy until serum potassium > 3.5 mmol/L
	Normal	3.3–5.2 mmol/L: give 20–30 mmol in each liter of IV fluid to maintain serum potassium of 4–5 mmol/L	3.5–5.0 mmol/L: give 10–20 mmol in each liter of IV fluid to maintain serum potassium of 4–5 mmol/L
	High	> 5.2 mmol/L: do not give potassium but check serum potassium every 2 hours	> 5.0 mmol/L: do not give potassium but check serum potassium every 2 hours