From the Guidelines
A blood glucose level above 350 mg/dL does not automatically require emergency department referral, but it warrants prompt attention, as the most recent and highest quality study suggests individualization of treatment based on a careful clinical and laboratory assessment is needed 1. The decision to refer a patient to the emergency department depends on the patient's symptoms, overall condition, and ability to manage their diabetes.
Key Considerations
- If the patient is experiencing symptoms of diabetic ketoacidosis (DKA) such as excessive thirst, frequent urination, nausea, vomiting, abdominal pain, confusion, fruity breath odor, or rapid breathing, they should go to the ED immediately.
- Similarly, if they have hyperosmolar hyperglycemic state (HHS) symptoms like extreme thirst, dry mouth, fever, weakness, confusion, or vision changes, emergency care is needed.
- For patients without these concerning symptoms, outpatient management may be appropriate with increased fluid intake, insulin adjustment per their management plan, and frequent glucose monitoring, as recent studies have shown that subcutaneous rapid-acting insulin analogs can be used in the emergency department or step-down units for treating mild or moderate DKA 1.
Management Goals
- Restoration of circulatory volume and tissue perfusion
- Resolution of ketoacidosis
- Correction of electrolyte imbalance and acidosis
- Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke
Important Notes
- The use of bicarbonate in patients with DKA is generally not recommended, as several studies have shown that it made no difference in the resolution of acidosis or time to discharge 1.
- Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
From the FDA Drug Label
Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin ... In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) ... If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.
Severe hyperglycemia requires immediate medical attention. If a patient's glucose level is higher than 350, it is crucial to seek emergency medical help to prevent potential life-threatening complications such as diabetic ketoacidosis (DKA) or death 2.
From the Research
Hyperglycemic Crisis Management
- Hyperglycemic crisis, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS), is a metabolic emergency that requires prompt management 3, 4, 5, 6, 7.
- The management of DKA and HHS involves aggressive administration of intravenous fluids, insulin therapy, and electrolyte replacement 3, 5, 6.
- Patients with glucose levels higher than 350 may be at risk for hyperglycemic crisis, and emergency department evaluation is crucial for timely identification and treatment 7.
- ICU admission is indicated in the management of DKA, HHS, and mixed cases in the presence of cardiovascular instability, inability to protect the airway, obtundation, or other severe symptoms 5, 6.
Diagnostic and Management Considerations
- Diagnostic criteria for DKA and HHS include hyperglycemia, metabolic acidosis, and ketonuria or ketonemia 5, 7.
- Management strategies involve fluid replacement, insulin therapy, and electrolyte management, with careful monitoring of the patient's condition 3, 4, 5, 6.
- The use of sodium bicarbonate is controversial and should be considered on a case-by-case basis 6.
- A quick reference algorithm and guide to management can aid in the rapid assessment and treatment of patients with hyperglycemic crisis 6, 7.