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Hyperglycaemic Emergencies in Diabetes

Recognize specific syndrome
Diabetic Mixed Hyperosmolar
Ketoacidosis (DKA) Hyperglycaemic
state (HHS)

Polyuria, polypsia, ≥5% dehydration in ALL

Acute (<1-2 days) Gradual (several days) Kussmaul respiration Depressed
LOC Nausea, vomiting Combativeness Abdominal pain Seizures Depressed
LOC
BG1) >11 mmol/l BG >33.3 mmol/l Cap ẞOHB2) ≥3 mmol/l3)
Absent or low Cap ẞOHB
(UK4) ≥2+)
(small UK)
Venous pH <7.3 Venous pH <7.25 or Arterial pH <7.3
SB5) <15 mmol/l SB <15 mmol/l Osmolality >320 mOsm/kg
Na > 160 mmol/l
Setting: Ingestion of high
Setting: T2DM,
carbohydrate containing
higher insulin reserve
drinks
(e.g. chemotherapy induced)

1) Blood glucose; 2) Capillary ẞ-hydroxybutyrate ;3) Normal cap ẞOHB = ≤ 0.6 mmol/l; 4) Urinary ketones (acetoacetate),5) Standard bicarbonate

Beware euglycaemic DKA

Setting: Starvation, Banting diet, liver failure, alcohol abuse, SGLT2-inhibitors (Dapagliflozin,
Empagliflozin).

Assess severity of DKA

Mild Moderate Severe

Acidosis pH <7,3 pH < 7,2 pH < 7.1

SB <15 SB <10 SB <5

Differentiate shock from stress response

Shock: Tachycardia ± hypotension, poor pulse volume, delayed capillary refill time
(Refer to N SBP and HR in appendix)
Stress response: Tachycardia and hypertension / SBP in upper normal range.

Calculate:
Effective Osmolality =2(Na) + BG m0sm/kg (N=280-295) [Na uncorrected; assesses
dehydration]
Corrected Na = measured Na + 2(BG-5.6)/5.6 mmol/l
[Anion gap = Na-(Cl+HCO3) (N=8-16)] – only necessary if ẞOHB not available]

Refer to ICU
1. HHS
2. Depressed LOC (not associated with initial shock).
3. Requiring ≥40ml/kg of NS to correct shock.
4. Anuria – persistent or redeveloping after shock was corrected

Consider ICU admission: Patients at risk for cerebral oedema (CO)

1. pH <7,1
2. Elevated urea
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3. Children under 2 years.

If intubated and ventilated: DKA patients need to hyperventilated to blow off CO2 (consult ICU
consultant); consider NG drainage.

Urinary catheter: As a general rule, only required if the child has a depressed LOC.

On admission:
1. Weight is essential
2. Laboratory glucose
3. pH, pCO2, SB, base deficit – indicate whether venous/arterial
4. Na, K, CI, U, Cr, Ca, Mg, Pi, albumin.
5. Infection screen if indicated (NB: Raised WCC typical during DKA)
Essential: Results to be available in 60 min – phone (& inform of testing
frequency) Please phone to arrange an emergency lab number on the following
numbers: 8am - 9pm: Chem path reg on call – cell: 079 873 0976
9pm – 8am: Lab – 021/9384904/4931/4934/6957/4330
Gatekeeper (or if afterhours medical superintendent) must be informed that extra tests will be
required on the patient.
Please do not rely on porters and take specimens to lab (Chempath lift and stairs are marked
“Resuscitation C/D East”)

Fluid therapy

1. Resuscitation
1) Shock (hypotension) • Oxygen.
• NS 0,9% 20ml/kg as fast as possible
(with syringe!)
Aim: N SBP for age and a significant drop
(of at least 10%) in HR.
Stay with the child until shock is corrected

2) Compensated shock/poor • NS 0,9% 10ml/kg over 15 min (with

tissue perfusion syringe!) Stay with the child until perfusion
has improved.

3) HHS • NS 0.9% 20ml/kg over 15 min (with syringe!)

4) Dehydration only • NS 0,9% 10ml/kg over 30 min

5) Mild DKA • Nil

Start insulin only if shock has been corrected (early use is associated with CO)

Reassess after 1), 2), 3):.

 • Repeat fluid bolus until aim achieved & no signs of fluid overload
• Consider ICU admission (see indications above)

2. Maintenance (over 24hrs)

≤ 10 kg 100ml/kg/24 hrs

11-20 kg 1000 ml + 50ml/kg/24hr for each kg from 11-20

> 20 kg 1500 ml + 20 ml/kg/24hr for each kg > 20

Obese children: Use ideal body weight for height

+
3. Rehydration (over 48 hours)
5% dehydrated 50ml/kg/48hrs

10% dehydrated 100ml/kg/48hrs

Review at least 2 hourly.

+/-
4. Ongoing losses
3
Replace urine loss in excess = urine output in ml/kg/hr – 2 ml/kg/hr
of 2ml/kg/hour

Review at least 2 hourly

NB: IV/oral fluid given in another facility must be factored into calculations.
Aims of fluid management:
DKA
1. Gradually reduce effective osmolality to normal i.e. at 4 hrs it should be
the same or up to 4mOsm/kg higher than at baseline (an early drop may
be associated with CO).
2. Na should rise by 0.5 mmol/l for each 1 mmol/l decrease in BG.
HHS
1. Gradually reduce Na and effective osmolality to normal
2. Na should decrease by 0.5 mmol/l/hr.

Fluids & electrolytes for maintenance, rehydration and ongoing

losses Type depends on haemodynamic status, serum Na, Cl &
osmolality.
1. In DKA, start with normal saline (NS) (0,9%)
In HHS, start with ½ NS (0,45%)
2. Change NS to ½ NS if serum Cl:Na >0.79
3. Add potassium unless in renal failure: 20 mmol KCl (10ml; 15%)+ 20 mmol K2PO4 (10ml) to 1
litre (i.e. 40 mmol K total)
a) Normokalaemic (N ECG; reference values – see appendix C): Start after resuscitation. b)
Hypokalaemic (ECG: prolonged PR, flattened/inverted T waves, ST depression, prominent U
waves, apparent long QT): During resuscitation - only give 20 mmol K.
 c) K < 2.5 mmol/l: Delay insulin therapy until K >2.5 mmol/l.
d) Hyperkalaemic (ECG: tall peaked T waves, short QT): Defer until urine output is
documented.
Maximum IV K rate: 0.5 mmol/kg/hr
If hypokalaemia persists in spite of max IV K rate: Insulin rate can be reduced. 4.
Add 5% dextrose to NS/½NS when BG <17 mmol/l or if BG drops by >5mmol/l/hr
Amount to be added to maintain BG at 11 (8 – 12) mmol/l:
5% = 50 g (100ml 50%) dextrose water (D/W) to 900 ml NS/½NS
(7.5% = 75 g (150ml 50%) D/W to 850 ml NS/½NS)
10% = 100 g (200ml 50%) D/W to 800 ml NS/½NS
12.5% = 125 g (250ml 50) D/W to 750 ml NS/½NS
If BG drops < 8 mmol/l in spite above, 2 ml/kg 10% D/W IV may be given to correct
it If BG is persistently < 8 mmol/l in spite of above: Half insulin infusion rate.

Note: Mixed HHS & DKA – requires more fluids than a classic case of DKA.

Meticulous monitoring: Secret to success

1 Nurse seconded to look after patient.
ECG monitor needed. Use flow chart.
1) Hourly HR, RR, BP (see Appendix A)
2) Hourly cap BG
3) 2 hourly cap ẞOHB
4) 1-2 hourly neurological observations in all drowsy and severe patients:
a) Glasgow coma scale (see Appendix B)
b) Warning signs & symptoms of CO:
i) Onset of / worsening headache
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ii) 🡫HR, 🡫BP
iii) 🡫O2 saturation
iv) Recurrence of vomiting
v) Change of CNS status: restlessness, irritability, increased drowsiness, confusion,
incontinence
vi) Specific CNS signs: Cranial nerve palsies, abnormal pupillary responses, posturing,
seizures.
vii) Rapidly 🡫 Na (suggest diabetes insipidus associated with cerebral herniation)
5) 2-4 hourly Na, K, Cl, U, Ca, Mg, Pi – insert separate cannula for blood drawing. 6)
(Note: A point of care analyser is often inaccurate).
7) Accurate intake and output: 2hrly (preferably hourly)
8) Daily morning body weight

Note: In HHS
• Altered mental status common, but CO is rare.
• A decline in LOC once osmolality has improved, requires urgent investigation (brain
haemorrhage, dural sinus thrombosis, CO if Na corrected too rapid)

Insulin infusion
 DKA: Start insulin after resuscitation
Aim: ẞOHB should decrease by 0.5 mmol/l/hr
HHS: Insulin administration is initiated when BG is no longer declining at a rate
of 3mmol/l on IVF alone. This does not apply if there is significant ketonaemia.
Aim once on insulin: BG should decrease by 3-4 mmol/l/hr
Dose and method of administration:
50 u regular (soluble) insulin (Actrapid®) in 50 ml NS (1 u = 1 ml) given with
an infusion pump.
Prime the IV line with 20 ml of above solution prior to
administration. Rate:
DKA: ≥ 5 years: 0.1 units/kg/hour
< 5 years: 0.05 units/kg/hour
HHS: ≥ 5 years: 0.05 units/kg/hour
< 5 years: 0.025 units/kg/hour
(Dose is titrated in HHS to achieve above aim)

Examples of insulin infusion:

• If the child weighs 20 kg, mix 50u regular insulin with 50ml NS. At 0.1u/kg/hr, the infusion
pump should be set at 2ml/hr.
• If the child weighs 10 kg, mix 50u regular insulin with 50ml NS. At 0.05 u/kg/hr, the infusion
pump should be set at 0.5ml/hr.

Notes for referring doctor

1. Prior to transfer and start of insulin infusion the child must be adequately resuscitated. 2.
If the transfer to TBH is quick and the DKA is not severe, it may not be essential to
administer insulin in transit.
3. Once the child is adequately resuscitated at the referring institution, the insulin infusion
should be started, while waiting for emergency medical services for transfer. 4. All patients
with hyperglycaemic emergencies (unless mild) should be transferred with Specialised
Paediatric Retrieval including Neonatal Transfer (SPRINT), tel no: 021/9380300. 5. During
transfer with the SPRINT team, insulin infusion should continue, provided it is administered
with an infusion pump and the BG is checked every 30 minutes and a paramedic competent
in responding to a falling BG accompanies the child.
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6. Referring doctor to discuss status of the patient with the receiving doctor prior to transfer (tel
no: 021/9386378).

Alternative insulin regimes for referring doctor

1. 25 units regular insulin (Actrapid) in 100ml normal saline, run at (0.4 x weight in kg) ml/hr, via
an infusion pump – suitable for children with weight < 25kg.
2. 50 units regular insulin (Actrapid) in 100ml normal saline, run at (0.2 x weight in kg) ml/hr, via
an infusion pump – suitable for children with weight < 25kg.
3. 50 units in 500ml normal saline (1 unit / 10ml), infuse at 0.1 units/kg/hour (if bag is in use for
> 24 hours, replace it).
4. Hourly subcut rapid acting insulin (aspart or lispro) or regular insulin (Actrapid) 0.1u/kg – this
should not be used if peripheral circulation is impaired.

Complications
 • CO • Hypokalaemia
• Hypocalcaemia, • Severe hypophosphataemia
hypomagnesaemia • • Venous thrombosis
Hypochloraemic alkalosis • Pulmonary embolism
• Hypoglycaemia • Aspiration pneumonia
• Dural sinus thrombosis, basilar artery • Pulmonary oedema
thrombosis, IC haemorrhage, • Rhabdomyolysis
cerebral infarction • Acute renal injury
• Sepsis • Acute pancreatitis
• Rhinocerebral/pulmonary
mucormycosis
• ARDS
• Pneumothorax,
pneumomediastinum, SC
emphysema
• Ischaemic bowel necrosis

Note: Complications listed on the right are more frequent in HHS.

Causes of persistent acidosis:

1. Inadequate resuscitation (high anion gap [AG], high lactate).
2. Errors in insulin administration (BG not dropping/rising, ẞOHB not decreasing/rising)
3. Sepsis (high AG, high lactate)
4. Hyperchloraemic acidosis (Cl:Na >0.79; Cl-induced base deficit = (Na – Cl) -32; AG can be N).

Sodium bicarbonate therapy: Never (causes paradoxical CNS acidosis &

CO) Exceptions:
• Venous pH < 6.9 & poor cardiac contractility
• Life threatening hyperkalaemia
In these cases give 1-2 mmol/kg over 60 minutes.

Treatment of CO
1. Initiate treatment as soon as CO is suspected.
2. Adjust fluid volume aiming to prevent hypotension as well as excessive fluid administration.
3. Elevate head to 30° and keep in midline position.
4. Mannitol 0.5-1g/kg IV over 10-15 min (effect should be apparent after 15 min and last for 2
hrs). If necessary, repeat dose after 30 min.
5. Hypertonic saline (3%) 2.5-5 ml/kg over 10-15 min – may be used as an alternative to
mannitol or if there was no response to mannitol within 15-30 min or if the patient is
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hyponatraemic (Caution: It has no benefits over mannitol and may be associated with a
higher mortality rate).
6. Intubate if impending respiratory failure due severe CNS compromise.
7. Admit to ICU.
8. Consider CT brain (esp. if intracerebral bleed or CVA suspected).

Mild DKA
1. Fluids ad lib (maintenance + 5% rehydration).
2. Fluid type:
 If BG > 11 mmol/l: clear water
If BG ≤ 11 mmol/l: If BG cannot be maintained by eating snacks and meals alone, non
carbonated sugar-containing fluids should be taken. If only carbonated fluids are available,
shake or stir the container until all bubbles are removed.
If diarrhoea or vomiting: Use oral rehydration solution.
3. Continue with the child’s usual insulin doses at the appropriate times.
4. Give hourly rapid acting insulin (Novorapid, Humalog, Apidra) at 0.1u/kg. If not available
regular insulin (Actrapid) may be used.
5. Continue with normal intake of 3 meals and 3 snacks per day. If needed, give additional snacks
to keep BG 11 mmol/l (prevents ketosis).
6. Monitor BG and cap ẞOHB hourly.
7. Continue hourly rapid/short acting insulin until cap ẞOHB ≤ 0.6 mmol/l.

Introduction of oral fluids and transition to SC insulin

1. Oral fluids should be introduced only when substantial clinical improvement has occurred
(mild acidosis/ketonaemia may still be present). Oral amount must be factored into
calculations.
2. When cap ẞOHB ≤ 0.6 mmol/l and oral fluids are tolerated, switch to SC insulin is planned.
3. Switch to SC insulin just before a meal time. Insulin infusion can be discontinued 1-2 hrs
after SC injection. If short- & intermediate-acting insulin are not given together (as in the
evening), discontinue insulin infusion after 2 hrs.
4. Known diabetic patients are re-started on their usual insulin dose. New diabetic patients,
coming out of DKA, are commenced on a dose of 1.0 u/kg/day (irrespective of size and
pubertal stage). The dose for new patients in mild/no DKA, should be discussed with the
endocrinologist on call. 2/3 of the total dose is (subdivided as 1/3 Actrapid and 2/3
Protophane) given ½ hr before breakfast and 1/3 in the evening (subdivided as 1/3 Actrapid
given ½ hr before supper and 2/3 Protophane at bedtime).
5. If necessary, corrective doses can be given in addition to the usual Actrapid dose ½ hr
before breakfast and supper. Dose: 0,05u/kg if BG >11 mmol/l and 0,1u/kg if BG ≥15
mmol/l.
6. The dietician should order the appropriate meal plan as soon as possible.
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December 2019 (Based on ISPAD guideline 2018)

Copies of this protocol may be requested from Salome Engelbrecht C3a
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APPENDIX A
NORMAL VALUES FOR INFANTS AND CHILDREN IN THE EMERGENCY ROOM
AND PAEDIATRIC WARDS

AGE PULSE RESPIRATORY SYSTOLIC

RATE BLOOD PRESSURE

< 2 Months 120-170 30-60 65-85

 2- 12 months 110-160 25-50 70-90

1-2 years 100-150 20-40 80-95

2-5 years 95-140 20-40 80-100

5-12 years 80-120 20-25 90-110

> 12 years 60-100 15-20 100-120

Appendix B
Glasgow Coma Scale
Best eye response Best verbal response Best verbal Best motor response
response
(nonverbal
children)

1. No eye opening 1.No verbal 1. No response 1. No motor

2. Eyes open to pain response 2. No 2. Inconsolable, response 2.
3. Eyes open to words, only irritable, Extension to pain
verbal command incomprehensible restless, cries (decerebrate
4. Eyes open sounds; moaning 3. Inconsistently posture)
spontaneously 3. Words, but consolable and 3. Flexion to pain
incoherent* moans; makes vocal (decorticate
4. Confused, sounds posture) 4.
disoriented 4. Consolable when Withdrawal from
conversation† crying and interacts pain
5. Oriented, normal inappropriately 5. Localizes pain
conversation 5. Smiles, oriented 6. Obeys commands
to sound, follows
objects and
interacts

* Inappropriate words, random or exclamatory articulated speech, but no sustained conversational exchange
† Attention can be held; patient responds to questions coherently, but there is some disorientation and confusion
Best score = 15; Worst score = 3.

Appendix C
K reference intervals
Neonates 3.7-5.9 mmol/l

Infants 4.1-5.3 mmol/l

1 – 11.9 yrs 3.4-4.7 mmol/l

 ≥ 12 yrs 3.5-5.5 mmol/l

Appendix D
Useful Aid memoire:
SHIELD: Syndrome & severity; Hydration & fluids; Insulin infusion; Electrolytes & osmolality; Level
of consciousness & complications; Don’t forget to monitor;