Hyperglycaemic Emergencies and Glycaemic Safety in the Critically Ill Adult with Diabetes: A Narrative Review with Implementation Considerations for Indian Intensive Care Units

Gautam Shriram

doi:10.37022/wjcmpr.v8i2.414

Authors

Shriram Gautam Consultant Intensives and Anaesthesiologist, Department of Anaesthesia and Critical Care, Apollo Spectra Hospital, Rewa, Madhya Pradesh, India

Abstract

Background. Diabetes is a common comorbidity in intensive care, and India has one of the world’s largest diabetes burdens. Consensus guidance on hyperglycaemic emergencies was substantially revised in 2024, altering diagnostic thresholds, severity grading and treatment targets used since 2009. Many intensive care protocols have not yet been updated.

Objective. To summarise current guidance on recognition and management of diabetic ketoacidosis (DKA), euglycaemic DKA, sodium-glucose cotransporter-2 (SGLT2) inhibitor-associated ketoacidosis, hyperosmolar hyperglycaemic state (HHS) and mixed presentations in critically ill adults; review ICU glycaemic targets and insulin safety; and identify practical challenges in Indian units.

Methods. Narrative review of current international consensus documents, society guidelines and landmark randomised trials, identified through targeted PubMed searches and hand-searching references of major guidelines. No systematic search protocol or formal risk-of-bias/certainty assessment was undertaken; recommendations are therefore presented narratively, using the strength descriptors of their source guidelines.

Synthesis. The 2024 consensus report lowered the DKA glucose threshold to 200 mg/dL or a prior history of diabetes, recommended quantitative beta-hydroxybutyrate as the preferred ketone measure, removed the anion gap as a first-line criterion, and lowered HHS thresholds for effective osmolality and bicarbonate to 300 mOsm/kg and 15 mmol/L, respectively. Subcutaneous insulin is endorsed for mild and uncomplicated moderate DKA outside intensive care. Moderate glycaemic targets remain standard, whereas tight control (80–110 mg/dL) increases harm. Routine bicarbonate, aggressive potassium replacement and excessively slow osmolar correction are not supported.

Conclusions. Avoidable harm commonly results from superseded thresholds, treating glucose rather than metabolic state, and unsafe insulin administration without attention to potassium and feeding continuity. In Indian ICUs, implementation depends particularly on bedside ketone testing and adequate nursing capacity for safe insulin infusions.

Keywords:

Diabetic ketoacidosis, hyperosmolar hyperglycaemic state, euglycaemic ketoacidosis, SGLT2 inhibitors, critical care, glycaemic control, beta-hydroxybutyrate, India

DOI

https://doi.org/10.37022/wjcmpr.v8i2.414

References

1. Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycemic crises in adults with diabetes: a consensus report. Diabetes Care. 2024;47(8):1257-75. doi:10.2337/dci24-0032.

2. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-97.

3. Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. Crit Care Med. 2026;54(4):725-812. doi:10.1097/CCM.0000000000007075.

4. American Diabetes Association Professional Practice Committee. Standards of Care in Diabetes. Diabetes Care. [Year];[Volume](Suppl 1):[Pages]. [Cite the edition current at submission].

5. Dhatariya KK; Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults: an updated guideline. Diabet Med. 2022;39(6):e14788.

6. Mustafa OG, Haq M, Dashora U, Castro E, Dhatariya KK; Joint British Diabetes Societies for Inpatient Care Group. Management of hyperosmolar hyperglycaemic state (HHS) in adults: an updated guideline. Diabet Med. 2023;40(3):e15005.

7. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4 Suppl):S117-314.

8. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2022;102(5 Suppl):S1-127.

9. Alghamdi NA, Major P, Chaudhuri D, et al. Saline compared to balanced crystalloid in patients with diabetic ketoacidosis: a systematic review and meta-analysis of randomized controlled trials. Crit Care Explor. 2022;4(1):e0613.

10. Self WH, Evans CS, Jenkins CA, et al. Clinical effects of balanced crystalloids vs saline in adults with diabetic ketoacidosis: a subgroup analysis of cluster randomized clinical trials. JAMA Netw Open. 2020;3(11):e2024596.

11. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults (SMART). N Engl J Med. 2018;378(9):829-39.

12. Zampieri FG, Machado FR, Biondi RS, et al. Effect of intravenous fluid treatment with a balanced solution vs 0.9% saline solution on mortality in critically ill patients (BaSICS). JAMA. 2021;326(9):818-29.

13. Finfer S, Micallef S, Hammond N, et al. Balanced multielectrolyte solution versus saline in critically ill adults (PLUS). N Engl J Med. 2022;386(9):815-26.

14. Katz MA. Hyperglycemia-induced hyponatremia: calculation of expected serum sodium depression. N Engl J Med. 1973;289(16):843-4.

15. Hillier TA, Abbott RD, Barrett-Connor E. Hyponatremia: evaluating the correction factor for hyperglycemia. Am J Med. 1999;106(4):399-403.

16. Egi M, Bellomo R, Stachowski E, et al. Variability of blood glucose concentration and short-term mortality in critically ill patients. Anesthesiology. 2006;105(2):244-52.

17. Roberts GW, Quinn SJ, Valentine N, et al. Relative hyperglycemia, a marker of critical illness: introducing the stress hyperglycemia ratio. J Clin Endocrinol Metab. 2015;100(12):4490-7.

18. Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet. 2009;373(9677):1798-807.

19. Preiser JC, Chase JG, Hovorka R, et al. Glucose control in the ICU: a continuum of care? Lancet Diabetes Endocrinol. 2016;4(3):272-82.

20. Kilpatrick ES, Butler AE, Ostlundh L, Atkin SL, Sacks DB. Controversies around the measurement of blood ketones to diagnose and manage diabetic ketoacidosis. Diabetes Care. 2022;45(2):267-72.

21. Klocker AA, Phelan H, Twigg SM, Craig ME. Blood beta-hydroxybutyrate vs urine acetoacetate testing for the prevention and management of ketoacidosis in type 1 diabetes: a systematic review. Diabet Med. 2013;30(7):818-24.

22. Kamel KS, Halperin ML. Acid-base problems in diabetic ketoacidosis. N Engl J Med. 2015;372(6):546-54.

23. Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Gonzalez-Padilla DA. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database Syst Rev. 2016;(1):CD011281.

24. Umpierrez GE, Latif K, Stoever J, et al. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med. 2004;117(5):291-6.

25. Fadini GP, Bonora BM, Avogaro A. SGLT-2 inhibitors and diabetic ketoacidosis: data from the FDA Adverse Event Reporting System. Diabetologia. 2017;60(8):1385-9.

26. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2). Diabetes Care. 2007;30(9):2181-6.

27. Anjana RM, Unnikrishnan R, Deepa M, et al. Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study. Lancet Diabetes Endocrinol. 2023;11(7):474-89.

28. Research Society for the Study of Diabetes in India (RSSDI). Clinical practice recommendations for the management of type 2 diabetes mellitus. Int J Diabetes Dev Ctries. [Year];Volume:[Pages].

29. Indian Council of Medical Research. Guidelines for management of type 2 diabetes. New Delhi: Indian Council of Medical Research; [Year].

30. Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the International Consensus on Time in Range. Diabetes Care. 2019;42(8):1593-603.

31. Singer P, Blaser AR, Berger MM, et al. ESPEN practical and partially revised guideline: clinical nutrition in the intensive care unit. Clin Nutr. 2023;42(9):1671-89.

32. Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis. 2019;19(12):e405-21.

33. Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev. 2024;40(3):e3687.

34. Heyland DK, Patel J, Compher C, et al. The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet. 2023;401(10376):568-76.