Therapeutic Handbook - GGC Prescribing

Assessment / monitoring• Glucose – often exceeds 40 mmol/L• U&Es – patient is dehydrated and can be hypernatraemic• Venous blood gases – are relatively normal (not acidotic as seen in diabetic ketoacidosis (DKA))• Osmolality – is calculated by [2 x (Na + + K + ) + urea + glucose]. It is usually > 350 mosmol/kg• FBC – increase in Hb and WCC may indicate dehydration and infection• ECG – may show ischaemia or infarction• Chest x-ray• Urinalysis• MSSU / blood culturesGeneral management and drug therapyEndocrine SystemIV insulin and IV fluid replacement are the mainstays of treatment but both should be used morecautiously compared to DKA (see below).• Give oxygen therapy.• Central venous pressure (CVP) monitoring may be required to guide fluid replacement.• Insert nasogastric tube if consciousness level is reduced or protracted vomiting.• Insert urinary catheter.• Give thromboprophylaxis SC, if no contraindications.Enoxaparin SC 40 mg once daily (or 20 mg once daily if the eGFR is< 30 ml/minute/1.73m 2 ).IV FluidsAdminister: Sodium chloride IV 0.9%: Give 1st litre over 1 hour,2nd litre over 2 hours3rd litre over 4 hours4th litre over 6 hours and5th litre over 8 hours• Faster rehydration is inappropriate in hyperosmolar coma. The above regimen is a guideand should be reviewed in the elderly or patients with cardiac disease according to clinicalassessment of hydration and taking into account co-morbidities.• If the corrected sodium concentration is high (> 155 mmol/L) after the initial 1 - 2 litres ofsodium chloride, then 0.45% sodium chloride should be considered after discussion with theconsultant on-call or diabetes team. Serum electrolytes should be monitored closely.• When blood glucose (BG) level falls below 14 mmol/L add in 10% glucose at a rate of100 ml/hour.• Review the patient closely to determine hydration status and consider the need for, and rateof rehydration with sodium chloride 0.9% solution.Continues on next pagePage 280