Hyperglycaemia

Act now

1. 1

   Blood ketones 3 mmol/L or above with acidosis: follow the DKA topic.

3. 2

   Osmolality 320 mOsm/kg or above with glucose 30 mmol/L or above and no significant ketosis: treat as HHS.

Assess

• Type of diabetes and usual treatment; missed insulin; steroids; infection; eating or nil by mouth.
• DKA clues: vomiting, abdominal pain, deep breathing. HHS clues: severe dehydration, confusion, glucose often over 30 mmol/L.

Investigations

• Capillary ketones, venous gas, U&E, calculated osmolality (2 × Na⁺ + glucose + urea), infection screen, HbA1c.

Manage

• Well, no ketones: review the regimen; give a correction dose of rapid-acting insulin per local protocol and adjust usual doses.
• Steroid-induced: glucose rises in the afternoon — follow local/JBDS steroid guidance (often morning gliclazide or isophane insulin).
• Unable to eat or uncontrolled while unwell: variable-rate IV insulin — see the Variable-rate insulin topic.
• HHS: IV 0.9% sodium chloride first; fixed-rate insulin only once glucose stops falling with fluids alone (at the same time as fluids if ketones are raised). Aim for osmolality to fall 3–8 mOsm/kg/hour and sodium by no more than 10 mmol/L in 24 hours.

Escalate when

Doses and prescribing

Check the BNF and your local formulary before prescribing.