Wa0019.

PROTOCOL FOR THE MANAGEMENT OF DIABETIC HYPERGLYCEMIC
EMERGENCIES AT FEDERAL MEDICAL CENTER UMUAHIA
The following are the common hyperglycemic emergencies seen at the Federal Medical Center Umuahia
1. Diabetic Ketoacidosis (DKA)
2. Hyperosmolar Hyperglycemic State (HHS)
A) Common symptoms and signs of hyperglycemic emergencies:
DKA HHS
Polyuria Weakness
Polydipsia Polyuria
Marked fatigue Polydipsia
Nausea History of reduced fluid intake
Vomiting History of ingestion of glucose drinks
Mental stupor Severe Hyperglycemia, Hyperosmolarity
Frank coma Profound dehydration, lethargy
Dehydration (dry mucous membranes) Tarchycardia, dry mucous membranes
Rapid and deep respirations Orthostatic hypotension, confusion
Fruity" breath odor of acetone Reduced skin tugor, Shock
Postural hypotension
Tachycardia
Abdominal pain and tenderness
Mild hypothermia
1
B) Laboratory findings in Hyperglycemic emergencies:
Laboratory Values in Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar State (HHS)
DKA HHS
Glucose,a mmol/L (mg/dL) 13.9–33.3 (250–600) 33.3–66.6 (600–1200)
Sodium, meq/L 125–135 135–145
Potassiuma,b Normal to increased Normal
Magnesiuma Normal Normal
Osmolality (mOsm/mL) 300–320 330–380
Plasma ketonesa ++++ +/–
Serum bicarbonate,a meq/L <15 meq/L Normal to slightly reduced
Arterial pH 6.8–7.3 >7.3
Arterial PCO2,a mmHg 20–30 Normal
Anion gapa[Na – (Cl + HCO3)] Increased Normal to slightly increased
a
Large changes occur during treatment of DKA.
b
Although plasma levels may be normal or high at presentation, total-body stores are usually depleted.
C)
D)
E)
F) C) Management:
2
Algorithm for the management of hyperglycemic emergencies
1. Confirm diagnosis.
2. Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH <7.00 or
unconscious.
3. Assess: Serum electrolytes (K+, Na+, Mg2+, Cl–, bicarbonate, phosphate)
Acid-base status—pH, HCO3–, PCO2, beta-hydroxybutyrate
Renal function (creatinine, urine output)
Replace fluids: The extracellular fluid deficit should be replenished by infusing isotonic saline (0.9%
NaCl) intravenously as follows:
1 Litre start
1 Litre over 1hour
1 Litre over 2hours
1 Litre over next 4-6 hours
When blood glucose < 13.8mmol/l (250mg/dl), Infusion should be switched to 5% dextrose/saline, 1
Litre 8-12 hourly (this is to replace the intracellular water deficit) Typical fluid requirement is 6 Litres
in first 24 hours but fluid overload should be avoided in elderly patients. Subsequent fluid replacement
should be based on clinical response including urine output
Note= in elderly patients (>65years) or patients with Cardio-respiratory disease condition, give:
500mls start
500mls after 1 hour
500mls over 2hours
3
500mls over 4-6hourly
4. Administer short-acting insulin. Insulin therapy should be instituted as follows:
Soluble insulin (Actrapid or Humulin R) as bolus: 10units IM and 10units IV
Followed by 4-6units hourly until blood sugar is ≤ 13.8mmol/l (250mg/dL)
Blood glucose should be checked hourly. Insulin should be increased by 2units if a blood glucose fall
of 55-110mg/dl per hour was not been achieved. About 8-12units of soluble insulin should be added to
each 1 Litre of dextrose saline until patient adequately tolerated orally.
Insulin should be changed to subcutaneous pre-meal dosage at 0.6-0.8units/kg body weight/day or to
Intermediate acting insulin (Insulin Mixtard or Humulin 70/30) once patient was able to eat and drink
normally.
5. Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction,
cocaine)? Initiate appropriate workup for precipitating event (cultures, CXR, ECG).
6. Measure capillary glucose every 1–2 h; measure electrolytes (especially K +, bicarbonate,

phosphate) and anion gap every 4 h for first 24 h.
7. Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1–4 h.
8. Replace K+: Potassium should be added as Potassium Chloride (KCl) into 5% dextrose saline
infusion as follows:
If plasma potassium is < 3.5mmol/l, 40mmol KCl should be added into alternate intravenous 5%
dextrose saline infusions.
If plasma potassium is 3.5-5.0mmol/l, 20mmol KCl should added into alternate 5% dextrose saline
infusions.
If plasma potassium is > 5.0 mmol/l or patient is anuric, KCl should not be given.
4
9. Antibiotics; Broad spectrum antibiotics should be given if infection was suspected or
demonstrated.
Other measures that should be taken in the management of Hyperglycemic emergencies should include:
a) Catheterization if no urine was passed after 3hours.
b) Nasogastric tube should be passed to keep the stomach empty in unconscious patients, or if
vomiting is protracted.
c) Subcutaneous prophylactic Low Molecular Weight Heparin should be given to elderly, obese and
comatose patients at a dose of 20-40mg daily.
d) Plasma expander should be given if systolic BP was < 90mmHg or did not rise with intravenous
normal saline.
10. Continue above until patient is stable.
11. Identify and treat the precipitating factor
12. Administer long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion
and SC insulin injection.
Abbreviations: CXR, chest x-ray; ECG, electrocardiogram.
*Formula for calculating osmolality: [2Na+ (mmo/L) + 2K+ (mmol/L) + Serum Urea (mg/dL) + Plasma
glucose/18 (mg/dL) Normal range is 280-320 mOsmol/L]
*Formula for calculating Anion gap: [(Na+ + K+) – (Cl + HCO-3) Normal range is 10-18]
Dr Ezeani IU
Consultant Physician/ Endocrinologist
FMC, Umuahia, Abia state.

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PROTOCOL FOR THE MANAGEMENT OF DIABETIC HYPERGLYCEMIC

EMERGENCIES AT FEDERAL MEDICAL CENTER UMUAHIA

1. Diabetic Ketoacidosis (DKA)

2. Hyperosmolar Hyperglycemic State (HHS)

A) Common symptoms and signs of hyperglycemic emergencies:

Marked fatigue Polydipsia

Nausea History of reduced fluid intake

Vomiting History of ingestion of glucose drinks

Mental stupor Severe Hyperglycemia, Hyperosmolarity

Frank coma Profound dehydration, lethargy

Dehydration (dry mucous membranes) Tarchycardia, dry mucous membranes

Rapid and deep respirations Orthostatic hypotension, confusion

Fruity" breath odor of acetone Reduced skin tugor, Shock

Abdominal pain and tenderness

Sodium, meq/L 125–135 135–145

Potassiuma,b Normal to increased Normal

Magnesiuma Normal Normal

Osmolality (mOsm/mL) 300–320 330–380

Plasma ketonesa ++++ +/–

Serum bicarbonate,a meq/L <15 meq/L Normal to slightly reduced

Arterial pH 6.8–7.3 >7.3

Arterial PCO2,a mmHg 20–30 Normal

Anion gapa[Na – (Cl + HCO3)] Increased Normal to slightly increased

3. Assess: Serum electrolytes (K+, Na+, Mg2+, Cl–, bicarbonate, phosphate)

Acid-base status—pH, HCO3–, PCO2, beta-hydroxybutyrate

Renal function (creatinine, urine output)

NaCl) intravenously as follows:

1 Litre over 1hour

1 Litre over 2hours

1 Litre over next 4-6 hours

should be based on clinical response including urine output

500mls after 1 hour

500mls over 2hours

4. Administer short-acting insulin. Insulin therapy should be instituted as follows:

Soluble insulin (Actrapid or Humulin R) as bolus: 10units IM and 10units IV

Followed by 4-6units hourly until blood sugar is ≤ 13.8mmol/l (250mg/dL)

each 1 Litre of dextrose saline until patient adequately tolerated orally.

Insulin should be changed to subcutaneous pre-meal dosage at 0.6-0.8units/kg body weight/day or to

6. Measure capillary glucose every 1–2 h; measure electrolytes (especially K +, bicarbonate,

a) Catheterization if no urine was passed after 3hours.

comatose patients at a dose of 20-40mg daily.

10. Continue above until patient is stable.

11. Identify and treat the precipitating factor

Abbreviations: CXR, chest x-ray; ECG, electrocardiogram.

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