Hyperglycemia
ABCs
- ABCs, full vitals; consciousness, hydration
- definition → inpatient hyperglycemia: glucose > 10 mmol/L; persistent values need treatment review
- confirm → capillary glucose now; unexpected → repeat, or lab glucose, without delaying treatment
- NPO only if swallowing unsafe, consciousness impaired, vomiting ongoing, or another indication: not automatic in DKA
altered, vomiting or hypotensive → DKA / HHS until excluded
HPI & precipitants
- classic symptoms: polydipsia, polyuria, N/V, abdominal pain
- diabetes history, usual insulin regimen, basal doses, recent glucose trends, intake changes
- precipitants, identify and treat the cause
- missed, withheld, or inaccessible insulin; adherence difficulties; pump interruption or failure
- new infection → respiratory, urinary, abdominal, skin / wound, line-related (sepsis)
- ACS symptoms → chest pain, dyspnea, diaphoresis, atypical / silent presentations (ACS)
- recent steroids or other hyperglycemia-provoking drugs
- SGLT2 inhibitor use (euglycemic DKA risk)
- surgery, fasting, trauma, acute physiological stress
- stroke; pancreatitis
- pregnancy; alcohol or substance use (where relevant)
DKA & HHS criteria (2024 consensus)
DKA, all three
- glucose ≥ 11.1 mmol/L or known diabetes
- euglycemic DKA: glucose may be near normal (SGLT2 inhibitors, pregnancy, prolonged fasting); ketones and acidosis still diagnostic
- β-hydroxybutyrate ≥ 3 mmol/L, or urine ketones ≥ 2+ if blood ketones unavailable
- prefer blood β-hydroxybutyrate; urine ketones acceptable initially, not for monitoring resolution
- metabolic acidosis: pH < 7.3 and/or bicarbonate < 18 mmol/L
HHS, all four
- glucose ≥ 33.3 mmol/L
- effective osmolality > 300 mOsm/kg or total osmolality > 320 mOsm/kg
- β-hydroxybutyrate < 3 mmol/L
- pH ≥ 7.3 and bicarbonate ≥ 15 mmol/L
mixed DKA / HHS
- meets both: treat the dominant physiology; DKA insulin rate if ketoacidosis is significant
workup
immediate severity
- glucose, blood ketones, VBG / ABG
- electrolytes (potassium, bicarbonate), renal function
- calculated osmolality if HHS suspected
- mental status, volume status
diabetes assessment
- HbA1c, usual insulin / diabetes therapy
precipitant-directed, only when clinically indicated
- CBC, CRP ± PCT, cultures, urinalysis, CXR
- ECG, troponin, lipase, pregnancy testing
glucose monitoring, by intake and severity
- eating → before meals, bedtime
- not eating → every 4–6 h
- hyperglycemic emergency → hourly, or per local DKA / HHS protocol
management
glucose above 20 mmol/L, no DKA / HHS
- assess ketonemia, acidosis, dehydration, osmolality, electrolytes, precipitating illness
- does not by itself trigger ICU or IV insulin
correction insulin
- MOH / local correction-insulin protocol; one universal sliding scale is not safe for every inpatient
- adjust for usual dose, insulin sensitivity, renal function, oral intake, hypoglycemia risk
- correction-only insulin is short-term: persistent hyperglycemia → scheduled basal + prandial + correction insulin
- never omit basal insulin in type 1 diabetes, even when fasting, unless a specialist protocol directs it
DKA / HHS: baseline plan
- fluids, before insulin
- isotonic saline or balanced crystalloid
- no cardiac or renal compromise → 500–1,000 mL/h for the first 2–4 h (2024 consensus)
- reassess BP, perfusion, urine output, sodium and volume status; subsequent rate follows them
- older, cardiac or renal disease → smaller, reassessed volumes
- potassium: check before insulin → potassium
- K < 3.5 mmol/L → hold insulin, replace K, start insulin once K is safely above 3.5
- replace with the fluids as K falls during treatment
- insulin
- DKA, or mixed DKA / HHS with significant ketonemia or acidosis → regular insulin IV infusion 0.1 units/kg/hr
- pure HHS, no significant ketosis or acidosis → fluids first; insulin once indicated, commonly 0.05 units/kg/hr
- dextrose / adjust insulin: glucose < 13.9 mmol/L → add 5–10% dextrose, reduce insulin rate; continue until ketoacidosis / hyperosmolality resolves, not just until glucose normalizes
- monitoring: capillary glucose every 1–2 h; electrolytes, creatinine, phosphate, β-hydroxybutyrate, venous pH about every 4 h; watch for hypoglycemia and falling potassium
- resolution
- DKA → ketones < 0.6 mmol/L and pH ≥ 7.3 or bicarbonate ≥ 18 mmol/L
- HHS → osmolality < 300 mOsm/kg, urine output > 0.5 mL/kg/hr, cognition at baseline
- treat the precipitant: infection, ACS, missed insulin, drugs (HPI above)
- HHS differs: fluids do the early work; insulin later and lower (step 3); resolution is judged by osmolality and cognition, not ketones
- local DKA / HHS protocol and a monitored setting take priority where they differ
escalation
senior / diabetes team, urgently
- any DKA, HHS or mixed picture
- hyperglycemia persisting or worsening despite ward treatment; complex insulin needs
- significant electrolyte disturbance
- precipitant unclear or not controlled
critical care
- severe DKA: pH < 7.0, bicarbonate < 10 mmol/L, β-hydroxybutyrate > 6 mmol/L, stupor or coma
- HHS or mixed picture with marked hyperosmolality or neurological impairment
- shock, persistent hypotension, hypoxemia or organ failure
- severe potassium abnormality or arrhythmia; intensive electrolyte replacement needed
- critical precipitant: septic shock, ACS, stroke
- not improving, or fluid / monitoring needs beyond the ward
- mild–moderate uncomplicated DKA: monitored ward setting with trained staff, not ICU
evidence
| source | type |
|---|---|
| Umpierrez et al., 2024 international consensus on hyperglycemic crises (Diabetes Care 2024;47:1257) | international guideline |
| ADA Standards of Care in Diabetes 2026, §16 | international guideline |
| Kuwait MOH / hospital DKA-HHS protocol | local-protocol verification required |
insulin rates above follow international consensus (ADA Standards of Care 2026, 2024 hyperglycemic-crises consensus); not yet confirmed against a specific Kuwait MOH / hospital DKA-HHS protocol
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
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Last clinically reviewed · 17 August 2026 · Last updated · September 2026