DKA, HHS and hypoglycaemia

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Red flags

• Check the glucose in every sick, comatose or fitting diabetic patient within minutes — hypoglycaemia is the fastest reversible cause of coma
• Diabetic ketoacidosis needs the fixed-rate insulin infusion at 0.1 units/kg/h — fluid and potassium are given WITH it, never as a substitute
• Add glucose to the fluid once the blood glucose falls under 14 mmol/L — keep the fixed-rate insulin running until the ketosis resolves
• In HHS, fluid is the primary therapy — withhold insulin until osmolality stops falling on fluids alone unless there is ketonaemia, and aim for an osmolality fall of 3 to 8 mOsm/kg/h to avoid osmotic demyelination
• Never give insulin to a hypoglycaemic patient — give glucose 25 g IV (50 mL of 50 per cent dextrose) or glucagon, then find and fix the cause
• Insulin drives potassium intracellularly — replace potassium as the serum level falls during DKA treatment, and delay insulin if the starting level is critically low
• Routine bicarbonate is not indicated in DKA — it is reserved for the profoundly acidotic patient in extremis