How to manage severe hyperglycemia?

Management of Severe Hyperglycemia (32 mmol/L)

Severe hyperglycemia (32 mmol/L or approximately 576 mg/dL) requires immediate medical intervention with intravenous fluids and insulin therapy to prevent life-threatening complications and death.

Initial Assessment and Management

Immediate Steps

• Assess for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS)
  • Check for ketones in urine or blood
  • Assess mental status, hydration status
  • Evaluate vital signs for signs of shock or dehydration
• Initiate IV access immediately
• Begin fluid resuscitation with normal saline
  • Average requirement is approximately 9L over 48 hours for HHS 1
  • Ensure adequate urine output before starting potassium replacement

Laboratory Evaluation

• Blood glucose monitoring every 1-2 hours
• Electrolytes, particularly potassium, sodium, and phosphate
• Arterial or venous blood gas to assess acid-base status
• Complete blood count
• Renal function tests
• Urinalysis for ketones

Insulin Therapy

For Critically Ill Patients or Hyperglycemic Crisis

• Start continuous intravenous insulin infusion 2
  • Initial bolus: 0.15 units/kg IV
  • Followed by continuous infusion at 0.1 units/kg/hour
  • Titrate to achieve blood glucose reduction of 50-75 mg/dL per hour
  • Target blood glucose: 140-180 mg/dL
• For HHS specifically: start at lower insulin doses (0.025-0.05 units/kg/hour) to avoid rapid osmolar shifts 3

Transition to Subcutaneous Insulin

• Once patient is stable with glucose <250-300 mg/dL for at least 4-6 hours
• Calculate 24-hour insulin requirement based on IV infusion rate during previous 12 hours
• Administer first dose of subcutaneous insulin 1-2 hours before stopping IV insulin 2

Identifying and Treating Underlying Causes

Severe hyperglycemia is often precipitated by:

• Infection (most common cause) 2, 4
• Medication non-compliance
• Undiagnosed diabetes
• Corticosteroid therapy
• Substance abuse
• Acute illness or surgery

Thorough evaluation for these precipitating factors is essential, with prompt treatment of any underlying infection.

Monitoring for Complications

Watch for:

• Cerebral edema (particularly with rapid correction of hyperglycemia)
• Vascular occlusions (myocardial infarction, mesenteric artery occlusion)
• Rhabdomyolysis
• Disseminated intravascular coagulation
• Electrolyte abnormalities (especially hypokalemia)
• Hypoglycemia during treatment

Special Considerations

For Hyperosmolar Hyperglycemic State (HHS)

• More common in older adults with type 2 diabetes
• Higher mortality rate (approximately 15%) compared to DKA 4
• Requires more aggressive fluid resuscitation
• May need slower insulin infusion rates initially

For Diabetic Ketoacidosis (DKA)

• More common in type 1 diabetes
• Requires correction of acidosis and ketosis
• Mortality rate 3.4-4.6% 4

Prevention of Future Episodes

• Diabetes self-management education
• Instruction on sick day management
• Regular blood glucose monitoring
• Medication adherence
• Recognition of early warning signs
• Regular follow-up with healthcare providers

Clinical Pitfalls to Avoid

• Failing to identify and treat the underlying cause
• Inadequate fluid resuscitation
• Too rapid correction of hyperglycemia
• Inadequate monitoring of electrolytes, especially potassium
• Premature transition from IV to subcutaneous insulin
• Overlooking comorbid conditions that may be exacerbated by hyperglycemia

Severe hyperglycemia represents a medical emergency that requires prompt recognition and aggressive management to prevent significant morbidity and mortality. The cornerstone of treatment includes fluid resuscitation, insulin therapy, and identification and treatment of the underlying cause.