Severe Hyperglycaemia (Diabetic Ketoacidosis (DKA) & Hyperosmolar Hyperglycaemic State (HHS))

Description

Medicine Treatment

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ICD-10 Code: E10.0-1/E11.0-1/E12.0-1/E13.0-1/E14.0-1

DESCRIPTION

Clinical features of severe hyperglycaemia include: 

• Dehydration
• Drowsiness, confusion, coma
• Abdominal pain
• Acetone/ fruity-smelling breath
• Vomiting
• Elevated blood glucose
• Deep sighing respiration

MEDICINE TREATMENT

Adults

• Average fluid deficit 6 L, and may be as much as 12 L
• Be cautious in renal and cardiac disease
• In the absence of renal or cardiac compromise: 
• Sodium chloride 0.9%, IV, 15–20 mL/kg in the first hour
  • Subsequent infusion rate: 10 mL/kg/hour with 20 mL/kg boluses if shocked
  • Do not exceed 50 mL/kg in the first 4 hours
  • Correct estimated deficits over 24 hours

Refer urgently with drip in place and running at planned rate. 

• When referral will take more than 2 hours and a diagnosis of diabetes with hyperglycaemia is confirmed: 
• Insulin, short acting, IM, 0.1 unit/kg
  • When giving insulin IM, do not use insulin needle 

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CAUTION
- Do not administer short acting insulin if the serum electrolyte status, especially potassium is not known 
- Continue with fluids but delay giving insulin in these cases in consultation with referral facility as this delay should not negatively affect the patient, but hypokalaemia with resultant cardiac dysrhythmias definitely will

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Children

If in shock: 

• Sodium chloride 0.9%, IV, 20 mL/kg as a bolus
  • If shock not corrected, repeat the bolus
  • If a 3rd bolus is required, consult with paediatrician

If no shock or aftershock is corrected:

• Sodium chloride 0.9%, IV

Fluid rates of sodium chloride 0.9%, IV (if no shock) in children awaiting transfer	Check regularly for shock or increasing dehydration
Weight range  kg	Rate (mL/hr)  (2–10 kg: 6 mL/kg/hr)  (>10–20 kg: 5 mL/kg/hr)  (>20–40 kg: 4 mL/kg/hr)
>4–6	25
>6–10	40
>10–15	60
>15–20	85
>20–30	100
>30–45	150
>45–80	200

Refer urgently with drip in place and running at planned rate. 

When referral will take >2 hours and a diagnosis of diabetes with hyperglycaemia is confirmed and provided glucose is monitored hourly: 

• Insulin, short acting, IM, 0.1 units/kg after 1st hour of infusion of saline 
  • When giving insulin IM, do not use insulin needle

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2024 Edition