HYPEROSMOLAR HYPERGLYCAEMIC STATE

• 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 Collection of blood culture specimens guideline
• ECG
• Chest X-ray

• Treat cause
• Start on prophylactic LMWH unless contraindication
• If patient febrile and septic and no obvious cause can be found – see Sepsis, severe sepsis and septic shock 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

• Deliver insulin and IV fluid simultaneously
• only via a set incorporating anti-reflux valves through single cannula
• see Administration of IV insulin infusions and fluid infusions 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)

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, give1L 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 mm of Hg)- avoid giving potassium in first litre of fluid
• Then 1 L over 2 hours
• Then 1 L over 4 hours ( aim is to achieve positive fluid balance of 2-3 litres by 6 hours)
• Then 1 L over 8 hours
• 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

Previous Insulin regimen

• If patient taking long-acting insulin [e.g. glargine (Lantus), detemir (Levemir) or deguldec (Tresiba)], continue this
• 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 ( eg: 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

• 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, VBG 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

• Once blood glucose has fallen down 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 like heart failure & renal failure
• continue alongside 0.9% sodium chloride and potassium chloride but reduce infusion rate to ½ to avoid over replacement ( for eg: 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

• If glucose falls below 6 mmol/L, stop 5% glucose & change over to 10% glucose
• serum K⁺ >5.5, give 1L bag of glucose 10% over 8hrs
• serum K⁺ ≤5.5, give two 500 mL premixed bags of glucose 10% with 20 mmol potassium chloride; first over 4hr, next over following 4 hr
• Check capillary glucose in 1 hr

• 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

• 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

• In patient new to insulin, insulin requirements will fall initially as resistance falls
• ensure close supervision during this period
• Caution in patients with low or high BMI as dosing requirement and insulin sensitivity may vary
• Daily insulin requirement is 0.3–0.5 units/kg
• in elderly, renal failure (CKD stage 4 &5), severe hepatic failure or newly diagnosed type 1 diabetes, use 0.3 units/kg
• all other adult patients, use 0.5 units/kg
• e.g. in a 60 kg patient, total starting dose of insulin is either 18 units or 30 units over 24 hr
• e.g. in a 60 kg patient, total starting dose of insulin is 30 units over 24 hr
• Give 50% of the total dose as long-acting analogue (glargine, detemir or degludec) SC before evening meal or before bedtime

Either

• Divide the remaining 50% into 3 equal doses of quick-acting insulin (Novorapid, Humalog or Apidra) SC
• to be given before breakfast, lunch and evening meal

Or

• If twice daily pre-mixed insulin regimen to be used – ²/₃ of total dose can be given before breakfast and ¹/₃ before evening meal

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

• 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