• 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 Blood Culture 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 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 IV insulin and IV fluid via one cannula 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, give 1L 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 mmHg) - avoid giving potassium in first litre of fluid
• Then 1 L over 2 hr
• Then 1 L over 4 hr( aim is to achieve positive fluid balance of 2-3 litres by 6 hr)
• Then 1 L over 8 hr
• 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

• Continue long-acting insulin [e.g. glargine (Lantus^®, Toujeo^®, Semglee^®, Abasaglar^®), detemir (Levemir^®) or degudec (Tresiba^®)] if patient is already on it
  • 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 ( e.g. 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, venous blood glucose 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 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, e.g. heart failure & renal failure
  • continue alongside 0.9% sodium chloride and potassium chloride but reduce infusion rate to ½ to avoid over replacement ( for e.g.: 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 glucose 5% and change over to glucose 10%
• 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

• Seek assistance from diabetes team for SC insulin initiation
  • continue insulin infusion until seen by diabetes team

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