Acute Severe DKA and HHS — Comprehensive Integrated Diabetic Emergencies

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• ALWAYS check serum potassium BEFORE giving insulin. If K+ <3.3 mEq/L, delay insulin and begin potassium replacement with the fluids (20-30 mEq per litre of fluid; treatment goal 4-5 mEq/L) — insulin drives K+ intracellularly and risks life-threatening arrhythmia. This is the single most examined DKA principle.
• Use a weight-based fixed-rate intravenous insulin infusion (FRIII) at 0.1 units/kg/h. Guidelines that use a loading bolus give 0.1 units/kg IV followed by the same infusion rate — or 0.14 units/kg/h with no bolus. The infusion continues until ketonaemia resolves, not until glucose normalises.
• When glucose falls below 14 mmol/L, do NOT stop insulin — ADD a 5% or 10% glucose infusion and consider de-escalating the FRIII from 0.1 to 0.05 units/kg/h (JBDS). Insulin must continue to suppress ketogenesis; stopping it leaves the ketoacidosis untreated.
• Bicarbonate ONLY if arterial pH <6.9 (100 mmol NaHCO3 in 400 mL sterile water with 20 mEq KCl at 200 mL/h for 2 h until pH >7.0), or peri-intubation when pH <7.2 and/or bicarbonate <10 mEq/L. Randomised data from pH 6.9-7.1 show no benefit; reported harms include hypokalaemia, reduced tissue oxygen uptake, paradoxical CNS acidosis and cerebral oedema (RR 4.2 in children).
• Cerebral oedema is the leading cause of DKA death in children (mortality 20-40%; it accounts for 57-87% of DKA deaths in children; 1-5% of episodes). Signs: headache, deteriorating consciousness, seizures, sphincter incontinence, pupillary changes, bradycardia, rising blood pressure, respiratory arrest. Treat with mannitol infusion and mechanical ventilation (3% hypertonic saline is an accepted alternative). Correct slowly — no more than 3 mOsm/kg/h in children.
• HHS mortality (10-20%, about ten times DKA's under 1%) is driven by age, comorbidity and dehydration. FLUIDS are the primary treatment: JBDS estimates losses of 100-220 mL/kg and starts insulin (0.05 units/kg/h) only once osmolality stops falling with fluid replacement alone — unless there is significant ketonaemia.
• Do not lower osmolality too fast in HHS — JBDS aims for a decline of 3.0-8.0 mOsm/kg/h (ADA/Diabetes Canada under 3). Named harms to prevent include osmotic demyelination, fluid overload and VTE.