From the Guidelines
The treatment for a 45-year-old male with severe hyperglycemia (rbs 500 mg/dl) and hypotension (bp 90/50) requires immediate fluid resuscitation and insulin therapy, as outlined in the most recent guidelines 1.
Initial Management
- Administer 1-2 liters of normal saline (0.9% NaCl) intravenously over 1-2 hours to restore blood pressure, followed by continued fluid replacement at 250-500 mL/hour based on hemodynamic response.
- Start regular insulin as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hour, titrating to achieve a glucose reduction of 50-75 mg/dL per hour, as recommended for critically ill patients with hyperglycemia 1.
Monitoring and Adjustments
- The patient should be monitored hourly for glucose, electrolytes, and vital signs.
- Potassium replacement is essential once levels fall below 5.2 mEq/L, typically giving 20-30 mEq/L in IV fluids.
- Once blood pressure stabilizes and glucose falls below 250 mg/dL, transition to IV fluids containing 5% dextrose while continuing insulin to prevent hypoglycemia.
Considerations
- The use of bicarbonate is generally not recommended in the treatment of diabetic ketoacidosis or hyperosmolar hyperglycemic state, unless there is a severe acidotic state 1.
- The patient's treatment should be individualized based on a careful clinical and laboratory assessment, and any underlying cause of the hyperglycemic state should be addressed, such as sepsis or other infections 1.
From the FDA Drug Label
Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath.
The patient has severe hyperglycemia with a blood glucose level of 500 mg/dL and hypotension with a blood pressure of 90/50.
- The treatment should focus on correcting the hyperglycemia and hypotension.
- Intravenous insulin therapy, as described in the study 2, can be used to rapidly lower blood glucose levels.
- The initial dose of intravenous insulin can be adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL).
- It is essential to monitor the patient's blood glucose levels and blood pressure closely and adjust the treatment as needed to prevent complications such as diabetic ketoacidosis (DKA).
From the Research
Treatment Approach
- The patient's condition, with severe hyperglycemia (RBS 500 mg/dl) and hypotension (BP 90/50), suggests diabetic ketoacidosis (DKA) 3.
- Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event along with frequent monitoring of the patient's clinical and laboratory states 3.
Fluid Resuscitation
- Traditional guidelines recommend isotonic normal saline (NS) for initial volume replacement in DKA patients 4.
- However, recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 4, 5.
- Balanced fluids, such as lactated Ringers, may be a better choice for initial resuscitation in DKA patients, as they may reduce the risk of complications related to hyperchloremia and improve clinical outcomes 4, 5.
Insulin Therapy
- Insulin therapy is a crucial component of DKA management, and blood glucose levels should be managed using basal, prandial, and/or correction insulin 6.
- Conservative blood glucose targets (140 to 180 mg per dL) are preferred during hospitalization to reduce the length of stay, mortality, and the risk of hypoglycemic events in critically ill patients 6.