MANAGEMENT
OF SEVERE HYPERGLYCAEMIA
1)
Confirm the diagnosis by a finger prick blood glucose test. Urine test
for ketosis.
2)
Assess if possible Na+, K+ and Urea
3)
Start 500-ml saline i.v. (0.9%)
4)
Examine for precipitating cause.
Thorough clinical
examination (if not already done)
Further tests? (Bs, urine
test, chest x-ray, spinal tap)
5)
Insert a catheter and monitor urine output.
6)
Give 20 IU soluble insulin i.m. and 10 IU i.m. hourly thereafter.
7)
Start therapy against precipitating illness (e.g. pneumonia, urinary
tract infection etc).
8)
If no evidence of heart failure; give 1.5l of 0.9% saline during the
first hour.
(Most patients with severe
hyperglycaemia have a deficit of 5-10 litres).
10 mmol of KCL is added to
the second and each subsequent 500-ml bottle of saline.
9)
Give fluid at a rate of 500-1000ml/hour depending of dehydration and
cardiac function.
10)
Repeat b-glucose and electrolytes after 2 hours. Reduce insulin dose to
5 IU hourly when b-glucose is below 22 mmol/l.
11)
Continue insulin and fluid replacement until b-glucose is 10-13 mmol/l.
Then change to i.v. glucose or dextrose with 10 mmol of K+ and 6 IU soluble
insulin 3-hourly (500 ml).
12)
Measure b-glucose 2 hourly and adjust the rate of insulin to maintain
b-glucose around 10 mmol/l. Saline can be given in parallel if the patient is
still dehydrated.
13)
Continue insulin and glucose or dextrose treatment until acidosis has
seemingly disappeared and the patient feels able to eat and drink. Remember
that excretion of ketone in the urine may continue for several days because
they are dissolved in body fat.
Differential diagnosis of impaired consciousness in diabetes mellitus
1
Malaria, stroke subarachnoid haemorrhage, severe infections and self
poisoning
2
hypoglycaemia
How to distinguish hyper- from hypoglycaemia as a cause of drowsiness
or coma
Hypoglycaemia Hyperglycaemia
Sudden onset More gradual (hours,days)
Profuse sweating Thirsty and polyuria
Pallor vomiting, abdominal pain
Drowsiness, lethargy and
weakness may occur with both
Urine test is
unhelpful Urine test invariably
strongly positive for glucose. Ketone bodies may be present
(Be aware that
small machines often are
unreliable and give to high or to low
results).
1 Loss of sodium around 700 mmol
However, measurements of both Na+ and K+ in serum reveal
only slight abnormalities due to concentration.