What are the management guidelines for a patient with severe hyperglycemia after receiving 12 units of insulin?

Management of Severe Hyperglycemia (Blood Sugar 440) After Initial Insulin Dose

For a patient with severe hyperglycemia (blood sugar 440 mg/dL) who has already received 12 units of insulin, continuous intravenous insulin therapy is the standard of care, especially if the patient shows signs of metabolic decompensation. 1

Initial Assessment

1. Check for ketosis immediately:

   • Test urine or blood for ketones
   • If ketonuria 2+ or ketonaemia ≥1.5 mmol/L: Transfer to ICU for IV insulin infusion therapy 1
   • If ketonuria 0-1+ or ketonaemia <1.5 mmol/L: Continue management with additional subcutaneous insulin

2. Assess for signs of dehydration and metabolic decompensation:

   • Mental status changes
   • Vital sign abnormalities (tachycardia, hypotension)
   • Nausea/vomiting
   • Abdominal pain
   • Fruity breath odor

Management Algorithm

If DKA or HHS is suspected:

1. Initiate IV fluids:

   • Normal saline at initial rate of 15-20 mL/kg/hr for the first hour

2. Start continuous IV insulin:

   • Initial dose: 0.1 units/kg/hr
   • Adjust based on hourly blood glucose monitoring
   • Target glucose decrease: 50-75 mg/dL/hr 1

3. Monitor electrolytes closely:

   • Particularly potassium (hypokalaemia occurs in ~50% of cases during treatment) 1
   • Replace electrolytes as needed

If patient has severe hyperglycemia without DKA/HHS:

1. Additional subcutaneous insulin:

   • For blood glucose >16.5 mmol/L (>300 mg/dL): Give 6 IU ultra-rapid analogue SC 1
   • Recheck blood glucose in 3 hours

2. Implement basal-bolus insulin regimen:

   • Total daily dose: 0.5 units/kg for insulin-naïve patients 1
   • Distribution: 50% basal insulin, 50% as prandial insulin divided into three doses 1
   • Lower doses (0.3 units/kg) for elderly patients (>65 years), those with renal failure, or poor oral intake 1

3. Avoid sliding scale insulin alone as it's associated with poorer glycemic control and higher rates of complications compared to basal-bolus regimens 1

Monitoring and Follow-up

1. Frequent blood glucose monitoring:

   • Every 1-2 hours until stable
   • Then every 4-6 hours 1

2. Watch for hypoglycemia:

   • Symptoms: sweating, drowsiness, dizziness, tremor, hunger, confusion 2
   • Have glucose tablets or IV glucose readily available
   • Treat if blood glucose <70 mg/dL with 15-20g oral carbohydrates 1

3. Identify and treat underlying causes:

   • Infection/sepsis
   • Medication non-adherence
   • New-onset diabetes
   • Steroid use

Special Considerations

• For patients on steroids: Consider higher insulin doses (0.3-0.5 units/kg/day) with greater proportion as prandial insulin to address afternoon and evening hyperglycemia 1, 3

• For patients with renal or hepatic impairment: Use lower insulin doses (0.3 units/kg/day) to prevent hypoglycemia 1

• For patients receiving nutrition: Adjust insulin regimen based on feeding method:

  • For continuous enteral feeding: Regular insulin every 6h or rapid-acting insulin every 4h
  • For bolus feeding: Insulin before each feeding
  • For parenteral nutrition: Add regular insulin to TPN solution 1

Transition Plan

When transitioning from IV to subcutaneous insulin:

1. Calculate total daily dose based on IV requirements:

   • Total SC dose = Total amount of insulin infused in 24h
   • Basal insulin = 1/2 of total daily IV insulin dose
   • Prandial insulin = Remaining 1/2 divided into 3 doses 1

2. Administer first dose of basal insulin 1-2 hours before discontinuing IV insulin to prevent rebound hyperglycemia

Common Pitfalls to Avoid

1. Relying solely on sliding scale insulin - This approach is strongly discouraged as it leads to poor glycemic control 1

2. Aggressive correction leading to hypoglycemia - Aim for gradual correction; severe hypoglycemia can be life-threatening 2

3. Failing to identify and treat underlying causes - Always search for the trigger of severe hyperglycemia

4. Inadequate monitoring - Frequent glucose checks are essential during initial management

5. Neglecting electrolyte monitoring - Particularly potassium during insulin treatment 1