Hyperglycemia

at the bedside

full vitals; consciousness, hydration
definition → glucose > 10 mmol/L; persistent values need the regimen reviewed
confirm → capillary glucose now; unexpected → repeat or lab glucose, without delaying treatment
NPO only if swallowing is unsafe, consciousness impaired or vomiting; not automatic in DKA

altered, vomiting or hypotensive → DKA / HHS until excluded

VBG + blood ketones now; large-bore IV access
fluids before insulin → 0.9% saline or balanced crystalloid, bolus if shocked, then the rate in step 1 of the DKA / HHS plan
then potassium and insulin per the plan

escalate now if

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
critical precipitant → septic shock, ACS, stroke
not improving, or monitoring needs beyond the ward

symptoms → polydipsia, polyuria, vomiting, abdominal pain
diabetes type, usual insulin regimen and basal dose, recent glucose trend, intake
precipitants
- missed or held insulin; pump failure
- infection → fever
- ACS, often silent in diabetes → chest pain
- steroids; SGLT2 inhibitors (euglycemic DKA)
- surgery, fasting, trauma, stroke, pancreatitis
- pregnancy; alcohol

lab glucose, blood ketones, VBG
RFT with potassium and bicarbonate; calculated osmolality if HHS suspected
HbA1c
by precipitant → CBC, CRP, cultures, urinalysis, CXR; ECG, troponin, lipase, pregnancy test

DKA and HHS criteria

DKA, all three

glucose ≥ 11.1 mmol/L or known diabetes
- euglycemic DKA (SGLT2 inhibitors, pregnancy, fasting): glucose near normal, ketones and acidosis still diagnostic
β-hydroxybutyrate ≥ 3 mmol/L, or urine ketones ≥ 2+ if blood ketones unavailable
- urine ketones are acceptable at diagnosis, not for monitoring resolution
metabolic acidosis → pH < 7.3 and/or bicarbonate < 18 mmol/L

HHS, all four

mixed DKA / HHS

glucose above 20 mmol/L, no DKA / HHS

correction insulin

local correction-insulin protocol, scaled to usual dose, renal function, oral intake and hypoglycemia risk
correction alone is short-term: persistent hyperglycemia → scheduled basal + prandial + correction; start basal 0.2–0.3 units/kg/day and prandial 0.05–0.1 units/kg/meal if eating → inpatient hyperglycemia, insulin
never omit basal insulin in type 1 diabetes, even when fasting

DKA / HHS: baseline plan

fluids, before insulin
- 0.9% saline or balanced crystalloid 500–1,000 mL/h IV for the first 2–4 h if no cardiac or renal disease
- older, cardiac or renal disease → smaller volumes, reassess after each
- then rate by BP, perfusion, urine output and sodium
potassium → check K before insulin (potassium)
- K < 3.5 mmol/L → hold insulin, replace K first, start insulin once K is above 3.5
- add K to the fluids as it falls during treatment
insulin
- DKA or mixed → regular insulin IV infusion 0.1 units/kg/hr
- pure HHS → fluids first; then regular insulin IV infusion 0.05 units/kg/hr
glucose < 13.9 mmol/L → add dextrose 5–10% IV and reduce the insulin rate; continue insulin until the ketoacidosis or hyperosmolality resolves, not until glucose normalises; bicarbonate only if pH < 7.0, with the senior
monitor → capillary glucose every 1–2 h; K, creatinine, phosphate, ketones and venous pH every 4 h; watch for hypoglycemia and falling K
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

HHS → fluids do the early work, insulin comes later and lower; resolution is judged by osmolality and cognition, not ketones
where the local DKA / HHS protocol differs, follow it

senior / diabetes team

any DKA, HHS or mixed picture; mild to moderate uncomplicated DKA can stay on a monitored ward
hyperglycemia persisting despite ward treatment
significant electrolyte disturbance; precipitant unclear

hand over → glucose and ketone trend, fluid and insulin rates, last K, next gas due, escalation trigger

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

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

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reviewed 17 Aug 2026updated Oct 2026file vital/hyperglycemia