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Takeafocusedhistorytoidentifypresentingfeaturesofhyperglycaemiaincluding:
Polyuria Thirst Urinaryfrequency Urinaryurgency Vomiting Weightloss.
Askaboutinfectivesymptomsthatmayhavecausedhyperglycaemia,e.g.respiratoryand urinarysymptoms. Establish whether the patientisknownto be diabeticand ask about alcohol intake and medication (including compliance with antiglycaemic drugs, recent medicationchanges,andsteroiduse).Askaboutfamilyhistoryofdiabetes(includingage ofonset),andinfemalesaskabouthyperglycaemiaduringpreviouspregnancies.
Themostcommoncausesofhyperglycaemiaareacuteillness,non-compliancewith diabetic medication,andalcohol.
Examination
Begin your examination with a general inspection. Signs such as vomiting, abdominal tenderness,andreducedconsciousnessshouldalertyoutoa possiblediagnosis ofDKA orHHS.
Performafullphysicalexaminationlookingforsignsofinfection.Thisshouldinclude listeningtothechest,examiningtheabdomen,andassessingtheskinforsignsofcellulitis andulcers.
Assess volume status; typically, hyperglycaemia will lead to dehydration and may presentwithclinicalsignssuchas:
Tachycardia Hypotensionorposturalhypotension Drymucousmembranes Raisedcapillaryrefilltime>2seconds Reducedskinturgor.
Sweet ‘pear-drop’ breathsuggests underlying ketosis andshould heighten your suspicion of DKA.
Investigations
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Bedside
CBG Serum ketones should be measured in people with T1DM with persistent hyperglycaemia (>2 readingsabove12mmol/L,atleast1hourapart),orinanypatientifunwell.InterpretasperTable
17.1
Sendurineforcultureifurinarytractinfectionissuspected Sputumsampleifthepatientisproducingpurulentsputum Skinswabsifindicated.
BeawarethatpatientswithT2DMtakingSGLTinhibitors (e.g.dapagliflozin,empagliflozin, and canagliflozin) can present with euglycaemic DKA. In this situation, the CBG may be normalbutthepatientmayhaveketoacidosis. Itisimportanttocheckbloodketone levelsin thesepatients.
Table17.1Interpretationofserumketones
Serumketones(mmol/L) Actiontobetaken
<0.6 Normal
0.6–1.4 Checkin2hours
1.5–2.9 Checkin1hour,considerDKA
>3 PerformVBGtocheckpH,considertreatingasDKA
Note:urinaryketonesarealsoused,areadingof>2+shouldpromptthemeasurementofserumketones andVBG.
ReproducedunderaCreativeCommonsLicence(CCBY-NC4.0)fromTheuseofvariablerate intravenousinsulininfusion(VRIII)inmedicalinpatients.October2014.JointBritishDiabetes Societies,InpatientCareGroup(JBDS09).
Bloods
FBC CRP U&E LFT Serumglucose HbA1c VBG Bloodculturesifthepatientispyrexial.
Imaging
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• ChestX-rayifchestinfectionissuspected.
Management
A singlereadingof elevatedbloodglucoseinanotherwisewellperson maynotrequire intervention. If an obvious cause of hyperglycaemia is identified (e.g. infection), this shouldbetreated.Ifapatientisunwell,considertheneedforaVRII(sometimesreferred toasa‘slidingscale’)andIVfluids.
Acutemanagement
Persistenthyperglycaemia
IfDKA(seeChapter15)orHHS(seeChapter18)aredetected,theseshouldbetreatedas pertheirguidelines.
Themanagementofsteroid-inducedhyperglycaemiaiscoveredlaterinthischapter.
AVRIIisindicatedinanunwellpatientwithaCBG>10mmol/L,withoutDKAorHHS, iftheyarenoteatingordrinking.
If a VRII is not indicated, and the patient is being treated with glucose-lowering medications,e.g.gliclazide,theseshouldbeoptimized.Ifthepatientisbeingtreatedwith insulin, consider a ‘correction’ dose of short-acting insulin (2–4 units) if required or increasetheinsulinregimen.
Be careful to avoid overnight hypoglycaemia due to overtreatment of high blood glucose beforebedtime.
SettingupVRIIs
Thisisaninfusionoffast-actingorshort-actinginsulin(e.g.Actrapid®).Thestartingrate dependsonthemostrecentCBG.Initiallypatientsshouldbestartedonthestandard-rate regimen (Table 17.2). If CBGs remain high despite the VRII (i.e. in insulin-resistant patients),theratesmaybe changed to an increased rateregimen. If the patientbecomes hypoglycaemicor is known tobe veryinsulin sensitive, itmaybe appropriate to usea reduced-rateregimen.
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Table17.2Starting(standard)rateofVRII
Capillarybloodsugar(mmol/L) Startingrate(mL/hour)
<4 0
4.1–8.0 1
8.1–12.0 2
12.1–16.0 4
16.0–20.0 5
20.1–24.0 6
>24.0 8
AdaptedunderaCreativeCommonsLicence(CCBY-NC4.0)fromTheuseofvariablerateintravenous insulininfusion(VRIII)inmedicalinpatients.October2014.JointBritishDiabetesSocieties,Inpatient CareGroup(JBDS09).
Regularlong-actingsubcutaneousinsulinshouldalwaysbecontinuedalongsideaVRII.
Fluidresuscitation
IfreceivingaVRII,patientswillrequireIVfluidsasperlocalguidelines.Elderlypatients atrisk offluidoverloadshouldreceive25–30mL/kgin 24hours (usuallyapproximately 2L).Patientswhoaredehydrated,e.g.vomiting,willrequireadditionalIVfluidtoreplace losses.
If a patient is at risk of fluid overload, e.g. heart failure, consider using smaller volumesof10%glucoseratherthangreatervolumesofalowerpercentageglucose.
Insulin drives potassium (K+) into cells, therefore consider concurrent potassium chloride(KCL)replacementdependingonK+level:
K+>5.5:noreplacementrequired K+3.5–5.5:supplementwith0.15%KCL(20mmol) K+<3.5:supplementwith0.3%KCL(40mmol).
Ifusing0.9%sodiumchloride(NaCl)forIVfluid,whenglucoselevelsare<14mmol/L, considerswitchingfromNaClto5%dextrosetoavoidhypoglycaemia.
Remember:whileonaVRIIitisimportanttoregularlymeasurepH,glucose,K+,andketones tomonitorclinicalimprovement.
Treatmentafterstabilization
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DiscontinuingVRIIs
When a patientiseatingand drinkingwithstablebloodsugar levels,considerstopping the VRII. Ensure they have eaten a meal at least 30 minutes before restarting oral hyperglycaemicmedication.MeasureCBG1hourafterstoppingtheVRII,andfourtimes overthenext24hourstoensurethatthereisnoreboundhyperglycaemia.
Consider a referral to the diabetes team of anyone who has required IV insulin treatment.
Specialconsiderations
Steroid-inducedhyperglycaemia
Steroids causehyperglycaemia andglucoselevelsshould be expected to rise4–8 hours afteranoralsteroiddose,orsoonerfollowingaparenteraldose.
Often,butnotalways,glucoselevelsimproveasthesteroiddoseisreducedorstopped; therefore,anytreatmentthathasbeeninitiatedwillneedtobetitrateddownagain.
Ifapatienthassteroid-inducedhyperglycaemia,theyshouldbetestedfordiabetes(see
Chapter26)atleast6weeksaftertheirsteroidcoursehascompleted.
Glucosemonitoringfrequencyforpatientsonsteroidtherapy
Patientswithoutadiabetesdiagnosis:OD.If>12mmol/L,escalatetestingfrequencytoQDS Patientswithadiabetesdiagnosis:QDStesting.
Treatingsteroid-inducedhyperglycaemia
IfCBGis>12mmol/Lmorethantwicein24hours,commencetreatment.
Insulin treatment may be more appropriate than oral treatment if hyperglycaemia persiststhroughouttheday.
If the patient is acutely unwell, they should be started on a VRII pending specialist diabetesteamreview.
Optionsfortreatment
Non-diabetic
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Sulfonylurea,e.g.gliclazide,startingdose40mgOD 10unitsofbasalinsulintobegiveninthemorning,e.g.Humulin®I,Insuman®Basal
Amultipledailyinjectionregimenmayberequiredforsteroidtreatmentsinvolvingmultipledaily dosages.
T1DM
Increaseinsulindosagesby2unitsevery24–48hoursandseekspecialistdiabetesteamreview.
T2DMnotreceivinginsulintherapy
Commencegliclazide40mgODorescalatecurrentdoseby40mgifthepatientisalreadytakingit (maximumdose240mginthemorning,maximumdailydose320mg) Metformin,escalatedosetoamaximumof1gBD.
T2DMalreadyoninsulintherapy
Iftakingbasalinsulinintheevening,considerswitchingthedosetomorning.
Patientswithdiabeteswhoareundergoingsurgery
ThisguidanceiscoveredinChapters92and93.
Furtherreading
1.RaineT,CollinsG,HallC,etal.(2018).Hyperglycaemia.In:OxfordHandbookfortheFoundation
Programme,5thed(p.330).Oxford:OxfordUniversityPress.
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Chapter18
Hyperglycaemichyperosmolarsyndrome
Guideline: Joint British Diabetes Societies Inpatient Care Group (The
managementofthehyperosmolarhyperglycaemicstate(HHS)inadultswith diabetes):
https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_06_The_Management_of_Hyperosmolar_Hyperglycaemic_State_HHS_%20in_Adults_FINAL_0.pdf
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Hyperglycaemichyperosmolarstate(HHS)isamedicalemergencywithamortalityof10– 20%.1Ittypicallyaffectsolderpatients,sometimesasafirstpresentationofT2DMandit developsoverdays,ascomparedwithDKA(seeChapter14)whichdevelopsoverhours. HHSischaracterizedbyseveredehydrationalongwithhyperglycaemiawhichresultsina hyperosmolar state. Treatment involves rehydration and restoration of electrolyte disturbancesinacautiousmannerthatavoidsrapidanddangerouscellularfluidshifts.
Diagnosis
History/diagnosticcriteria
Diagnosisshouldbeconsideredwhenthefollowingfeaturesarepresent:
Severedehydration—indicatedbyhypovolaemiaandhypernatraemia Marked hyperglycaemia (≥30mmol/L) without significant hyperketonaemia (<3mmol/L) or acidosis(pH>7.3,bicarbonate>15mmol/L) Osmolality≥320mOsm/kg.
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PatientscanpresentwithamixtureofHHSandDKA.Considerinthepresenceofsignificant hyperketonaemia.
Examination
Systematically examine the patient using an ABCDE approach (Table 18.1). Hyperglycaemiaresultsinanosmoticdiuresiswhichcausesdehydration.
Table18.1HHSexaminationfindings
A
Checkforevidenceofairwaycompromiseduetoreducedconsciouslevel
B
Hypoxia
C
Tachycardia Hypotension JVPnotvisible Coolperipheries Prolongedcapillaryrefilltime
D
↓GCSscoreiscommonwhenosmolality>330mOsm/kg Limbweaknessmaybeasignofraisedurea
E
Sunkeneyesandlongitudinalfurrowsonthetonguesuggestdehydration Examinefeetforulceration
CallforhelpearlyinHHSpatients
The patient usually has some impairment of conscious level due to significant metabolic derangement and they may be more dehydrated than they appear—water moves from cells into the extracellular space, temporarily preserving intravascular volume.
Investigations
Use biochemicalparametersinconjunctionwithclinicalfindings. Look forprecipitating factors,e.g.infectionoravascularevent.
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Bedside
Point-of-carecapillaryglucoseandketones UrinalysisandMC&S ECG—cardiaceventscanbeaprecipitantorcomplicationofHHS.
Bloods
FBC U&E:
Tocalculateosmolality(Box18.1) If patientshaveacuteorchronickidneyinjury,thismaybecontributingtotheiracidosisand willneedstrictfluidbalancemanagement
CRP VBG(includingHCO
3
–
/lactate)
Serumglucoseandketones HbA1c Bloodcultures.
Box18.1Osmolalitycalculation
2Na++glucose+urea
Imaging
ChestX-ray.
Escalation
Considerescalationtohigherdependencycareifanyofthefollowingarepresent:
SerumpH<7.1(DKAmaycoexist) Potassiumderangementonadmission GCSscore<12 Oxygensaturation<92%onair Signs of shock: systolic blood pressure <90mmHg, heart rate >100bpm or <60bpm, or hypothermia Signs of severe dehydration: osmolality >350mOsm/kg, sodium >160mmol/L, or creatinine >200µmol/L Macrovascularevent,e.g.myocardialinfarctionorotherseriouscomorbidity.
Management
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Acutemanagement
Correct biochemical abnormalities slowly to prevent vascular complications and avoid pathology caused by rapid cellular fluid shifts (e.g. sudden drop in blood pressure, cerebraloedema,centralpontinemyelinolysis).
Afterinitialassessment,usethetreatmentalgorithm(Fig.18.1)to:
Normalizeosmolality(Box18.1) Replacefluid/electrolytelosses(Box18.2andTable18.2) Reduceglucose(aimtoreduceto10–15mmol/L).
Box18.2Expectaninitialriseinsodium
Serum osmolality reduces when blood glucose is lowered. Water shifts into the intracellular space,andserumsodiumconcentrationrises A fallin glucoseof5.5mmol/L willcausea2.4mmol/Lrise insodium.Arisegreaterthanthis indicatesinadequatefluidresuscitation Risingsodiumisonlyaconcernifosmolalityisnotfallingconcurrently.
Source:Themanagementofthehyperosmolarhyperglycaemicstate(HHS)inadults.February2022. JointBritishDiabetesSocieties,InpatientCareGroup(JBDS06).
Table18.2Potassiumreplacement—aimtomaintainwithinnormalrange
Potassiumlevelinfirst24hours(mmol/L) Potassiumreplacementininfusionsolution
>5.5 Nil
3.5–5.5 40mmol/L
<3.5 Seniorreview—additionalpotassiumrequired
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