Last Modified: 1:20pm 16/04/2021
Hour 1: Immediate management upon diagnosis: 0 to 60 minutes
T=0 at time intravenous fluids are commenced. If there is a problem with intravenous access critical care support should be requested immediately.
Commence IV 0.9% sodium chloride – 1 litre to run over 1 hour
o Consider more rapid replacement if SBP below 90 mmHg
o Caution in the elderly where too rapid rehydration may precipitate heart failure but insufficient may fail to reverse acute kidney injury.
Only commence insulin infusion (0.05 units/kg/hr) IF there is significant ketonaemia (3β-hydroxy
butyrate greater than 1 mmol/L) or ketonuria 2+ or more (i.e. mixed DKA and HHS)
Clinical assessment of the patient:
o Does the history suggest sepsis/vascular event or a recent change in medication?
o Assess the degree of dehydration
o Examine for a source of sepsis or evidence of vascular event
o Mental state assessment
Assess foot risk score – assume high risk if patient obtunded or uncooperative
o Ensure heels are off-loaded
o Ensure daily foot checks
o Capillary BG
o Venous plasma BG
o Urea and electrolytes
o Measured or calculated osmolality (2Na+ + glucose + urea)
o Venous blood gas
o Blood ketones and lactate
o Full blood count
o Blood cultures
o Urinalysis and culture
o CRP (if indicated)
Establish monitoring regime appropriate to patient
Generally hourly blood glucose (BG), Na+, K+, urea and calculated osmolality (2Na+ + glucose + urea) for the first 6 hours then 2 hourly if response satisfactory (a fall of 3-8 mosmol/kg/hr).
- Chart osmolality / glucose / sodium
- Continuous pulse oximetry
- Consider continuous cardiac monitoring.
Insert urinary catheter to monitor hourly urine output and calculate fluid balance.
Commence prophylactic LMWH.
Consider IV antibiotics if sepsis identified or suspected
Ensure early senior review and/or inform specialist diabetes team.