Treatment Pathway and care guidelines for Diabetic
Ketoacidosis and Hyperglycaemic Hyperosmolar State
Diagnostic Tool / Criteria
For diagnostic criteria see Management of Diabetic Ketoacidosis and
Hyperglycaemic Hyperosmolar State (DKA and HHS) guidelines (already
submitted).
Community treatment and referral pathway
First aid guidelines for GP, patient will need admission if:
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Blood sugar greater than 14, despite treatment adjustments
Ketones equal to or greater than 2
Any signs and symptoms of DKA / HHS
Refer to medical team on call and admit to acute medical admission
ward for assessment.
First aid guidelines for ambulance crew / paramedics
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Follow medical emergencies guideline
Ensure airway maintained
Ensure high flow O2 therapy
Obtain IV access, and commence rehydration using sodium chloride
intravenous 0.9%, 250mls rapidly (up to 20ml/kg in children) and then
reassess vital signs, preferably on route to hospital
If vital signs and perfusion improve, slow down infusion “to keep vein
open” rate
If no improvement, give a further 250mls and reassess, repeating
process to maximum 2 litres of fluid (40ml/kg in children).
Provide hospital alert message / information call and transport to
nearest receiving hospital for urgent hospital treatment.
Acute DKA and HHS pathway
Follow Management of Diabetic Ketoacidosis and Hyperglycaemic
Hyperosmolar State (DKA and HHS) guidelines (already submitted).
For prescription and treatment in ward areas see Guideline for the
management of blood sugars in Hyperglycaemic emergencies in adults with
Diabetes (Diabetic ketoacidosis (DKA) and Hyperglycaemic Hyperosmolar
State (HHS)) (already submitted). In practice this form is colour coded to
yellow, ICP should follow this.
Discharge procedure
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Before discharge patient should be seen by Diabetes Specialist Nurse
for education regarding sick day rules.
Follow up appointment with Diabetologist
Referral to community DSN for ongoing support and contact advice.
Prevention and self management with first aid guidance
Ten key points:
1.
Be prepared, any illness can affect Diabetes and usually increase blood
2.
Blood glucose often rises, at times of illness, your body is under
glucose levels, so even if you are not eating or drinking very much, your
blood glucose can rise. Illnesses such as common cold, flu, abscesses, urinary
infections, stomach upsets, sore throats or bronchitis, can affect your
Diabetes.
Always have a supply of monitoring equipment and sugary fluids / sweets at
home.
stress and this usually raises your blood glucose levels. Do test your blood
glucose more regularly, every 2 - 4 hours depending on how poorly you are
feeling. If you are unable to check ask a friend or relative for help. If your
blood sugars are above 14 mmol/l, and you take Insulin injections, also check
your blood or urine for Ketones. (See point 6.)
3. Never Stop Taking Your Diabetes Medication / Insulin, even if you
are not eating or drinking very much.
4.
Consider alternative drinks / foods, try to drink plenty of liquids
such as water or sugar free squash, especially if your blood glucose is high
(hyperglycaemia) sip 3 - 4 litres a day. If your blood glucose is low
(hypoglycaemia under 4 mmol/l) drink sugary soft drinks, milk or fruit juices.
Aim for one small glass of sugary drink an hour (if your blood glucose is low)
as well as lots of water or sugar free drinks.
You maybe unable to eat your usual meals, and will need to have alternative
foods that have starch or ‘carbohydrate’ at regular intervals (every 2 - 3
hours) if your blood glucose is lower you may need to have it more often.
The foods / drinks below all contain 10 grams of Carbohydrate.
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200ml thickened/ broth based soup
1 plain yoghurt
1 dried fruit yoghurt
1 scoop of ice cream
3 Glucose tablets
1 sachet of Complan
50mls of Lucozade
100mls natural fruit juice
100mls of Cola, Lemonade or other full sugared fizzy drink (defizzed is
easier to sip)
200ml of milk
5.
Tell a friend or relative, if you are on your own, that you are ill, and
6.
Test for ketones, if you have insulin injections, and your blood sugars
ask them to check on you every 4 - 6 hours.
rise above 14 mmol/l or you are feeling nauseous, have been sick or have
abdominal discomfort test your urine or blood for ketones.
Ketones are a sign that your body is lacking insulin, and requires larger insulin
doses. If ketones persist or increase in quantity, you can become unwell due
to your diabetes. Do not exercise if ketones are present.
Ketone level
Actions required
Ketone levels of 1 or under in blood or
urine
An acceptable reading, and a sign that
your body is breaking down fat to
provide your fuel.
Ketone level of 1-2 in your blood or
urine
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An elevated reading and a sign that
extra insulin is required
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Test blood glucose and ketone
(urine or blood) every 2 hours
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Contact your GP or Diabetes centre
for ongoing advice
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This is a sign of serious diabetes
illness (Diabetic Ketoacidosis)
You should contact your GP or
attend A&E for immediate help and
medical treatment.
Ketone level of 2 -3 in your urine or
Blood
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7. Consider Having More Insulin.
When your blood glucose is above 14 mmol/l for more than 2 readings and
urine or blood ketones are present.
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Increase all future insulin doses by 1/5
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Continue to test blood glucose 1-2 hourly and urine or blood ketones
every 2 hours.
Blood glucose above 20 mmol/l or higher / and / or urine or blood ketones
present
 This requires immediate treatment
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If you use a clear quick acting, analogue insulin (Novorapid, Humalog
Lispro, Actrapid, Humulin S) take 8 units as an extra dose.
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If you have a twice a day insulin regime (Novomix 30, Humalog Mix 25 ,
Humalog Mix 50 or Human Mixtard 10, 20, 30, 40, 50 or Humulin M3 , M5)
take 1/5 of usual insulin (or 10 units if usual dose above 50 units) now as
extra dose.
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Continue to test your blood glucose every 1-2 hours and urine or blood
ketones every 2 hours and discuss making further increases with your GP
or Diabetes Specialist Nurse.
8.
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9.
Contact your GP or Diabetes Specialist Nurse for support when:
Vomiting or diarrhoea for more than 6 hours
Unable to eat or drink for 4 hours
Your illness has not improved after 2 days
You have had high blood glucose levels (above 14 mmol/l) for 24 - 48
hours with or without urinary or blood ketones.
Seek urgent medical advice from your GP, Diabetes Specialist Nurse
or Accident and Emergency Department if the signs of Diabetes Ketoacidosis
(dangerously high blood glucose and ketones) present, such as:
 Stomach pain
 Nausea or vomiting
 Rapid breathing or heart beat
 Fruity breath 'ketone breathe’
 Thirst or passing urine often
 Weakness or tiredness
 Visual changes / problems
 Sleepiness / problems staying awake
10.
Continue to monitor blood glucose regularly, when recovered
from illness, blood glucose levels should settle and insulin injections will
probably need reducing again. Contact your GP, Diabetes Specialist Nurse for
advice.