How do I manage a patient with hyperglycemia and ketosis on the ward?

Management of Hyperglycemia and Ketosis on the Ward

For patients with hyperglycemia and ketosis who are not candidates for ICU transfer, administer 6 IU of ultra-rapid acting insulin subcutaneously and monitor blood glucose and ketone levels 3 hours later. 1

Initial Assessment

When managing a patient with hyperglycemia and ketosis on the ward, first determine:

• Severity of hyperglycemia (blood glucose level)
• Degree of ketosis (ketonuria or ketonemia)
• Type of diabetes (T1D, T2D on insulin, or T2D on oral agents)
• Mental status and hydration status

Management Algorithm

Step 1: Evaluate Severity

• If blood glucose >16.5 mmol/L (>3 g/L), check for ketosis 1
• Assess ketone levels:
  • Ketonuria = 0 or ketonemia <0.5 mmol/L: Mild ketosis
  • Ketonuria 1+ or ketonemia 0.5-1.5 mmol/L: Moderate ketosis
  • Ketonuria 2+ or ketonemia >1.5 mmol/L: Severe ketosis (consider ICU)

Step 2: Initial Treatment

For mild to moderate ketosis:

• Administer 6 IU ultra-rapid acting insulin subcutaneously 1
• Ensure adequate hydration
• Monitor blood glucose and ketone levels after 3 hours

For severe hyperglycemia without significant ketosis:

• Add ultra-rapid acting insulin analog and ensure good hydration 1

Step 3: Ongoing Management

• Continue monitoring blood glucose every 2-4 hours 1
• Administer short-acting or rapid-acting insulin as needed based on glucose levels
• Ensure adequate fluid intake
• Monitor electrolytes, particularly potassium

Special Considerations

For Type 1 Diabetes

• More aggressive insulin management may be needed
• Resume basal-bolus insulin regimen as soon as ketosis resolves 1
• Ensure basal insulin is administered 2-4 hours before stopping any IV insulin to prevent rebound hyperglycemia 1

For Type 2 Diabetes

• If on insulin, resume previous regimen once ketosis resolves
• If on oral agents only, consider temporary insulin therapy until acute episode resolves 1

For Steroid-Induced Hyperglycemia

• Consider NPH insulin administered concomitantly with steroid doses 1
• For long-acting glucocorticoids, long-acting insulin may be required 1

Common Pitfalls to Avoid

1. Relying on nitroprusside method for ketone monitoring: This only measures acetoacetic acid and acetone, not β-hydroxybutyrate (the strongest and most prevalent acid in DKA). During treatment, β-hydroxybutyrate converts to acetoacetic acid, which may falsely suggest worsening ketosis 1

2. Abrupt discontinuation of insulin: When transitioning from IV to subcutaneous insulin, ensure overlap of 1-2 hours to prevent rebound hyperglycemia 1

3. Inadequate potassium monitoring: Hypokalaemia is common during treatment of hyperglycemic crises and can lead to increased mortality 1

4. Overlooking hyperosmolarity: In T2D patients with severe hyperglycemia, consider hyperosmolar state, which may present with subtle symptoms like asthenia, confusion, and dehydration 1

By following this structured approach, you can effectively manage patients with hyperglycemia and ketosis on the ward while monitoring for complications that would necessitate ICU transfer.