DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
RECOGNITION AND ASSESSMENT
- Use this guideline only in patients who have severe dehydration without metabolic acidosis
- For symptoms and signs, investigations and to check you are using the correct guideline, use Hyperglycaemia: triage guideline
Definition
- Severe hypovolaemia
- Marked hyperglycaemia (>30 mmol/L) without significant hyperketonaemia (capillary ketones <3 mmol/L), ketonuria (≤2+) or acidosis (pH >7.3, HCO3 >15 mmol/L)
- Serum osmolality usually >320 mosmol/kg or more (calculated as 2 x Na + urea + glucose)
Search for precipitating causes
- Sepsis (signs of shock)
- Recent myocardial infarction
- Pancreatitis
- Other causes
Investigations for causes
- Phosphate
- Amylase
- MSU
- If symptoms suggest sepsis, blood culture - see Blood Culture guideline
- ECG
- Chest X-ray
GENERAL MANAGEMENT
- Treat cause
- Start on prophylactic LMWH unless contraindication
- If patient febrile and septic and no obvious cause can be found - see Sepsis guideline
- If patient hypotensive or comatose, or fails to pass urine within 3 hr of starting IV fluids, introduce urethral catheter to monitor urine volume
- see Urethral catheterisation guideline
- If hypotension persists beyond 6 hr, look again for evidence of sepsis, myocardial infarction or pancreatitis - discuss further management with medical SpR and consider transfer to critical care
- If GCS <8, request review by critical care team for endotracheal intubation and insertion of a nasogastric tube in order to aspirate stomach
- If not on critical care, admit patient to endocrinology ward
DELIVERY OF FLUID AND INSULIN
- Deliver insulin and IV fluid simultaneously
- only via a set incorporating anti-reflux valves through single cannula
- see IV insulin and IV fluid via one cannula guideline
- Do not use ordinary 3-way taps
- Use IVAC pump to control IV fluid infusion rate and to alert when fluid bag needs replacing
- On admission, measure serum K+ and phosphate together with venous glucose
- whenever a bag of fluid is replaced, measure serum K+
- Never give single doses of insulin (e.g. Actrapid®)
INITIAL FLUID
Choice of fluid
- NEVER add potassium chloride to infusion bags
- Select pre-mixed bags of sodium chloride 0.9% and potassium chloride
- serum K+ ≥5.5 mmol/L, give 1L bag of sodium chloride 0.9%
- serum K+ 3.5-5.4 mmol/L, give 1L premixed bag of sodium chloride 0.9% with 40 mmol potassium chloride
- serum K+ <3.5 mmol/L, give two 500 mL premixed bags of sodium chloride 0.9% with 40 mmol potassium chloride
- Do not prescribe any K+ supplement in fluid running ≤1 hr
- If patient is anuric, do not give potassium
- While potassium is being infused, attach cardiac monitor to patient
Rate of fluid
- Give chosen pre-mixed bags of sodium chloride 0.9% and potassium chloride
- 1 L over 1 hour (consider more rapid replacement if SBP < 90 mmHg) - avoid giving potassium in first litre of fluid
- Then 1 L over 2 hr
- Then 1 L over 4 hr( aim is to achieve positive fluid balance of 2-3 litres by 6 hr)
- Then 1 L over 8 hr
- Repeat until glucose has fallen to 14 mmol/L, then then move to Glucose ≤14 MMOL/L section
- If plasma osmolality is not declining despite achieving adequate positive fluid balance, use sodium chloride 0.45% very carefully only after seeking senior help
INITIAL INSULIN
Previous Insulin regimen
- Continue long-acting insulin [e.g. glargine (Lantus®, Toujeo®, Semglee®, Abasaglar®), detemir (Levemir®) or degudec (Tresiba®)] if patient is already on it
- advise nurse to administer alongside IV insulin
- If patient on subcutaneous insulin pump (CSII), discontinue pump
- contact diabetes team or consultant in charge of patient
IV insulin delivery and infusion
- Use BD micro-fine insulin hypodermic syringes to accurately dose and draw insulin
- do not use ordinary syringe
- 50 units soluble insulin (Actrapid® or Humulin S®) diluted to 50 mL with sodium chloride 0.9% in 50 mL syringe
- Luer-lok through a spiral or long line delivered by syringe driver pump (so each mL equates to 1 unit of insulin)
Rate
- Commence insulin infusion using standard concentration of 50 units soluble insulin/50mL sodium chloride at 0.05 units/kg/hr ( e.g. in 80 kg body weight start @ 4 units/hr)
- if decline in capillary glucose <5 mmol/hr, increase insulin infusion by 1 unit/hr until this rate of decline is achieved
MONITOR
- Maintain a strict fluid intake/output chart
- Remember: always assess patient clinically for fluid status and response to treatment
- While potassium is being infused, attach cardiac monitor to patient
- Capillary glucose hourly for 6 hr, then 2-hrly if patient stable
- Capillary ketones hourly (if indicated) until falls to < 0.6 mmol/L
- Lab glucose, U&E, venous blood glucose 2 hr and 4 hr; then 2-4 hrly glucose and U&E till stable
- Monitor patient for complications of over-rapid treatment:
- hypoglycaemia
- cerebral oedema (decreased conscious level +/- focal neurological deficit) in absence of hypoglycaemia
- Adult Respiratory Distress Syndrome (ARDS); hypoxia resistant to high FiO2 - seek critical care opinion
GLUCOSE ≤14 MMOL/L
- Once blood glucose has fallen to 14 mmol/L, start 5% Glucose (to avoid cerebral oedema from too rapid fall in blood glucose ) at rate of 83-125 ml/hr-depending on patient's present fluid status & previous co-morbidities, e.g. heart failure & renal failure
- continue alongside 0.9% sodium chloride and potassium chloride but reduce infusion rate to ½ to avoid over replacement ( for e.g.: if running at 250ml/hr then reduce it to 125 ml/hr)
- Blood glucose may rise as a result. But do not stop Glucose infusion
Insulin infusion
- If blood glucose between 10-14 mmol/L, maintain same insulin infusion rate
- If blood glucose <10 mmol/L, reduce insulin infusion rate by 1 unit/hr until >10 mmol/L
GLUCOSE < 6MMOL/L
- If glucose falls below 6 mmol/L, stop glucose 5% and change over to glucose 10%
- Check capillary glucose in 1 hr
SUBSEQUENT MANAGEMENT
- Ensure continuing improvement of clinical and biochemical variables
- Continue treatment of any underlying precipitant
- Do not expect biochemistry to have normalised by 24 hr
- Continue IV fluids until eating and drinking normally
- When biochemically stable, convert to appropriate SC insulin regimen
CONVERSION FROM IV INSULIN
- Once patient biochemically stabilised (pH >7.3, capillary ketones <0.6 mmol/L) and able to eat and drink, convert to SC insulin regimen
Patient can't eat/drink
- When ketones normal and acidosis resolved, convert to variable rate insulin infusion as in Hyperglycaemia: can't eat/drink guideline
- Assess fluid requirement clinically and involve diabetes team
SC insulin
- Transition from IV to SC insulin should take place when the next meal-related SC insulin dose is due (e.g. with breakfast or lunch)
- If already on insulin, continue fixed-rate infusion for 30-60 min after SC insulin administration in conjunction with a meal
- If delay in obtaining diabetes team support, the following is guidance for insulin therapy
Previously using SC insulin dose
- Restart usual insulin
- increasing previous dose by 10-20% for first 2-3 days
Insulin naïve patients
- Seek assistance from diabetes team for SC insulin initiation
- continue insulin infusion until seen by diabetes team
Adjusting SC insulin regimen
- Once patient using SC insulin regimen, adjust doses to achieve target range of 6-11 mmol/L
- if using soluble insulin before breakfast, lunch and dinner, plus isophane at 2200 hr, use Table as guide to insulin adjustment, raising or lowering appropriate insulin by 2-4 units
- if patient usually using insulin analogue (e.g. lispro/aspart +/- glargine/detemir), additional isophane may be needed - discuss with diabetes team
DISCHARGE AND FOLLOW-UP
- Encourage early mobilisation
- Continue prophylactic LMWH until day of discharge (unless contraindicated)
- Check diabetes team have made appropriate follow-up arrangements or refer to diabetes team for out-patient review
- If patient new to insulin, prescribe needles for insulin pens, lancets and sharps guard