How to manage severe hyperglycemia (high blood sugar) of 600 mg/dL?

From the Guidelines

Severe hyperglycemia of 600 mg/dL requires immediate emergency medical attention with intravenous insulin therapy and aggressive fluid replacement, as it can be life-threatening. The most recent and highest quality study, 1, published in 2018, emphasizes the importance of individualized treatment based on a careful clinical and laboratory assessment.

Key Considerations

• The patient should be taken to an emergency room immediately for treatment with intravenous insulin therapy, typically starting with a bolus of regular insulin (0.1 units/kg) followed by continuous insulin infusion (0.1 units/kg/hour) as suggested by 1 and 1.
• Aggressive fluid replacement with normal saline is essential, often beginning at 15-20 mL/kg/hour for the first hour, then adjusted based on hydration status, as indicated in 1 and 1.
• Electrolyte replacement, particularly potassium, is crucial as levels will drop with insulin therapy, as noted in 1 and 1.
• The underlying cause must be identified and addressed, whether it's diabetic ketoacidosis, hyperosmolar hyperglycemic state, or another condition, as emphasized in 1.
• Blood glucose should be monitored hourly, with insulin rates adjusted to achieve a gradual decrease of 50-75 mg/dL per hour, as suggested by the example answer.
• Once blood glucose reaches 250-300 mg/dL, dextrose is typically added to prevent hypoglycemia while continuing insulin to clear ketones if present, as indicated in the example answer.

Management Goals

• Restoration of circulatory volume and tissue perfusion
• Resolution of hyperglycemia
• Correction of electrolyte imbalance and ketosis
• Treatment of any correctable underlying cause of DKA, such as sepsis, as noted in 1.

Important Considerations

• Continuous intravenous insulin is the standard of care for critically ill and mentally obtunded patients with DKA or hyperosmolar hyperglycemic state, as stated in 1.
• There is no significant difference in outcomes for intravenous regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA, as noted in 1.
• The use of bicarbonate in patients with DKA is generally not recommended, as it makes no difference in resolution of acidosis or time to discharge, as indicated in 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Severe Hyperglycemia

To manage severe hyperglycemia of 600 mg/dL, the following steps can be taken:

• Identify the underlying cause of the hyperglycemia, such as infection, insulin omission, or undiagnosed diabetes 2
• Assess the patient's clinical status, including hydration level, cognitive function, and presence of ketonaemia or acidosis 3
• Initiate fluid replacement with intravenous 0.9% sodium chloride to restore circulating volume, with caution in elderly patients 3
• Commence fixed rate intravenous insulin infusion (FRIII) once osmolality stops falling with fluid replacement, unless there is ketonaemia 3
• Monitor blood glucose levels and adjust insulin therapy as needed to achieve a gradual decline in blood glucose levels 3
• Replace electrolytes, including potassium, according to potassium levels 3
• Identify and treat any underlying precipitating factors, such as infection or substance abuse 2

Hyperosmolar Hyperglycaemic State (HHS)

If the patient is diagnosed with HHS, the following additional steps can be taken:

• Aim to improve clinical status and replace fluid losses by 24 hours 3
• Gradually decline osmolality by 3.0-8.0 mOsm/kg/h to minimize the risk of neurological complications 3
• Target blood glucose levels of 10-15 mmol/L in the first 24 hours 3
• Prevent hypoglycaemia and hypokalaemia through careful monitoring and adjustment of insulin and electrolyte therapy 3
• Prevent harm from complications such as venous thromboembolism (VTE), osmotic demyelination, fluid overload, and foot ulceration 3

Diabetic Ketoacidosis (DKA)

If the patient is diagnosed with DKA, the following additional steps can be taken:

• Restore circulating volume with fluid replacement 4, 2
• Administer insulin therapy to reduce blood glucose levels and ketoacidosis 4, 2
• Replace electrolytes, including potassium, according to potassium levels 4, 2
• Treat any underlying precipitating factors, such as infection or insulin omission 4, 2
• Monitor the patient's clinical status and adjust therapy as needed to prevent complications and improve outcomes 4, 2