Unifying Concepts

Diagnostic Criteria for Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

A diagnosis of diabetic ketoacidosis (DKA) requires the patient’s plasma glucose concentration to be above 250 mg per dL (although it usually is much higher), the pH level to be less than 7.30, and the bicarbonate level to be 18 mEq per L or less.

The hyperosmolar hyperglycemic state (HHS) is the most serious acute hyperglycemic emergency in patients with type 2 diabetes, characterized by severe hyperglycemia and glycosuria in the absence of Kussmaul breathing, with a fruity breath odor or positive acetone test in the urine. Current diagnostic HHS criteria include a plasma glucose level >600 mg/dL and increased effective plasma osmolality >320 mOsm/kg in the absence of ketoacidosis.


Diagnostic Criteria for Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

Mild DKA Moderate DKA Severe DKA HHS
Plasma glucose (mg per dL [mmol/L]) > 250 (13.9) > 250 > 250 600 (33.3)
Arterial pH 7.25 to 7.30 7.00 to 7.24 < 7.00 > 7.30
Serum bicarbonate (mEq/L) 15 to 18 10 to < 15 < 10 > 15
Urine ketones Positive Positive Positive Small
Serum ketones Positive Positive Positive Small
Beta-hydroxybutyrate High High High Normal or elevated
Effective serum osmolality (mOsm/kg)* Variable Variable Variable > 320
Anion gap† > 10 > 12 > 12 Variable
Alteration in sensoria or mental obtundation Alert Alert/drowsy Stupor/coma Stupor/coma

*Effective serum osmolality = 2 × measured Na (mEq/L) + (glucose [mg/dL] ÷ 18).
†Anion gap = Na+ – (Cl– + HCO3– [mEq/L]).




  1. Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. [Medline]
  2. Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014 Nov;37(11):3124-31. [Medline]
  3. Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. [Medline]
  4. Trachtenbarg DE. Diabetic ketoacidosis. Am Fam Physician. 2005 May 1;71(9):1705-14. [Medline]


Created Oct 15, 2020.


  • Language:

  • Users Online

  • Medical Disclaimer

    El contenido de este sitio web son solo para fines informativos y no reemplazan la consulta con un profesional médico.
  • Recent Posts

  • Categories

  • Copyright by