Therapy

Give intravenous fluids ^a - initially 0.9% saline ^c   
(e.g. 1 litre over 30 min, 1 litre over 1 h, 1 litre over 2 h, 1 litre over 4 h). 

• If none of the following are present, fluids can safely be given more slowly if necessary ^d  
  • circulatory shock
  • oliguria (<30ml/hr) during the first 4 hours of admission
  • renal insufficiency (urea > 21mmol/l or creatinine > 350 µmol/l).

Give soluble insulin  ^a in low-doses (e.g. 5 to 10 units per hour)  ^a  intravenously ^d at regular intervals or continuously. ^d

Monitor electrolytes ^c and capillary glucose frequently. ^d  
Give potassium supplementation ^a after insulin therapy has begun if K+ < 5.5 mmol/l. ^d Provide 10 to 30 mmol/h. ^c  

Give broad-spectrum antibiotics if there is evidence of infection. ^d

For patients with hyperglycaemic hyperosmolar nonketosis, give heparin 5000 units sc every 12 hours. ^d

Continue giving insulin until ^a

• glucose <10 mmol/l, and
• ketones are cleared (3-hydroxybutyrate <0.5 mmol/l)

• If glucose < 10 mmol/l but ketones are still raised, continue the insulin infusion with 5% or 10% glucose iv to maintain glucose 5 to 10 mmol/l.  ^c
• Once patients have stabilised and are eating, swap to subcutaneous insulin.  
  Give the first subcutaneous dose, then stop the infusion an hour later if your patient remains well. ^d

• sodium bicarbonate ^d 
• routine phosphate supplementation ^a  
• hypertonic glucose ^d