From the Guidelines
Hyperglycemia in the emergency department requires immediate intervention with individualized treatment based on a careful clinical and laboratory assessment, prioritizing restoration of circulatory volume, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, as outlined in the 2024 standards of care in diabetes 1. When managing hyperglycemia in the emergency department, it is crucial to consider the severity of symptoms and the presence of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).
- Key symptoms that necessitate immediate intervention include altered mental status, severe dehydration, persistent vomiting, fruity breath odor, Kussmaul respirations, or blood glucose levels above 600 mg/dL.
- Treatment should begin with IV fluid resuscitation, typically using normal saline, to restore circulatory volume and improve tissue perfusion.
- The administration of insulin, either intravenously or subcutaneously, depends on the severity of the condition and the patient's mental status, with continuous intravenous insulin being the standard of care for critically ill patients 1.
- It is also essential to identify and address any underlying cause of hyperglycemia, such as infection, medication non-compliance, myocardial infarction, stroke, or pancreatitis, to prevent recurrence and improve outcomes.
- Recent guidelines suggest that the use of bicarbonate in patients with DKA does not significantly impact the resolution of acidosis or time to discharge and is generally not recommended 1.
- Successful transition from intravenous to subcutaneous insulin requires careful planning, including the administration of basal insulin 2-4 hours before stopping intravenous insulin, to prevent rebound hyperglycemia and ketoacidosis 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Hyperglycemia in the Emergency Department
- Hyperglycemia is a common finding in patients presenting to the emergency department (ED) and is being recognized as a public health problem 2
- The presence of hyperglycemia increases the mortality and morbidity associated with the primary condition, and related hospital admission rates and costs are also elevated 2
- Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are hyperglycemic emergencies that commonly present to the ED, but the most common form of hyperglycemia in ED is associated with non-hyperglycemic medical emergencies 2
Management of Hyperglycemia
- Evidence suggests that better management of hyperglycemia in the ED with proper follow-up improves clinical outcomes and prevents readmission 2
- Optimization of the hyperglycemia management in the ED may improve clinical outcomes, but more clinical trial data on the outcomes and cost-effectiveness of various management strategies or protocols are needed 2
- Treatment options for hyperglycemia in the ED include metformin, long-acting insulin, or deferring for close outpatient management 3
- Insulin and dextrose are frequently used to manage patients with hyperkalemia, but hypoglycemia after insulin use is a frequent complication during hyperkalemia management 4
Diagnosis and Treatment of Hyperglycemic Emergencies
- A diagnosis of DKA is confirmed when all of the three criteria are present - elevated blood glucose levels, the presence of high urinary or blood ketoacids, and a high anion gap metabolic acidosis 5
- The mainstays of treatment for DKA include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 5
- The treatment of hyperosmolar hyperglycemic state must be tailored to individual patients and relies on aggressive fluid resuscitation, insulin replacement, and electrolyte management 6