Acute hyperglycemia without DKA
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priority, especially in patients with type 1 diabetes, is to rule out DKA
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And if DKA is confirmed, they should be managed along the lines of the DKA protocol I mentioned before
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Once DKA has been ruled out, the next priority after this is to make a decision on whether the patient can be treated as out-patient or will need to be admitted to hospital
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If the patient is clinically unwell, vomiting and unable to take orally, they need to be admitted to be stabilized in hospital
In-hospital treatment of acute hyperglycemia
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Clinical assessment to identify and treat reason for hyperglycemia e.g UTI, chest infection, etc.
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If dehydrated, treat with IV saline
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If on insulin: review insulin regime and step up insulin doses aiming for normoglycemia
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Continue basal insulin, adjust short-acting insulin according to monitored glucose levels
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Avoid using insulin sliding scales as it results in fluctuating levels
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Identify gaps in patient education and arrange for education by educator/dietician
When admitted, a clinical assessment should be performed to look for and treat any reasons for the hyperglycemia such as a urinary tract infection or chest infection
If they are dehydrated and not able to take oral fluids, IV saline should be started
And as for the specific treatment for the hyperglcyemia, if they are on insulin, their insulin regime should be reviewed and insulin doses should be stepped up to achieve normoglycemic targets.
Usually, the basal insulin would be continued and adjustment should be made to the dose of the short-acting insulin based on their monitored glucose levels.
We should avoid giving insulin via what is called the sliding scale, because it was shown to lead to large fluctuations in glucose levels
And when these patients are admitted, the opportunity should be taken to identify any gaps in their education and address it accordingly, making use of members of the diabetes team such as the diabetes educator or dietician
Out-patient management of acute hyperglycemia
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Suitable if patient is clinically well, eating and drinking normally
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Seek help from diabetes educator
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Give glycemic targets and step up insulin doses
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If on orals, consider transfer to insulin
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Advise to avoid dehydration
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Advise frequent glucose monitoring
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Advise checking for urinary ketones
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Re-educate on sick day rules
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Arrange follow up
Some patients who present with acute hyperglyemia are well enough to be treated as out-patient, this is usually the case if they are able to eat and drink normally
Again here one can make use of the diabetes educator
They should be given glycemic targets to aim for and should be advised on stepping up insulin doses
If they are on oral treatment, one can consider changing them to insulin
And they should be specifically advised to avoid dehydration by drinking plenty of non-sugary fluids
Those who are treated as out-patient should be advised to do more frequent glucose monitoring
Patients with type 1 diabetes, in particular, should also be advised to check for urinary ketones
They should be re-educated and remined about the sick day rules
And further follow up should be arranged