What is the management for severe hyperglycemia?

Management of Severe Hyperglycemia with Blood Glucose of 558 mg/dL

Immediate insulin therapy should be initiated for this severe hyperglycemia with a blood glucose of 558 mg/dL, targeting a glucose range of 140-180 mg/dL. 1

Initial Assessment and Management

1. Rule out diabetic ketoacidosis (DKA):

   • Check for ketones in blood or urine
   • Assess for signs of DKA: nausea, vomiting, abdominal pain, fruity breath odor
   • Obtain arterial blood gases if DKA is suspected 2

2. Immediate interventions:

   • Start intravenous (IV) fluid resuscitation with 0.9% NaCl at 15-20 mL/kg/hour initially 2
   • Begin IV insulin therapy after initial fluid resuscitation:
     • Start continuous IV insulin infusion at 0.1 units/kg/hour 2
     • Goal: decrease blood glucose by 50-75 mg/dL per hour 2

3. Monitor frequently:

   • Check blood glucose every 1-2 hours until stable
   • Monitor electrolytes, especially potassium, every 2-4 hours
   • Assess acid-base status if DKA is suspected 2

Specific Management Based on Clinical Scenario

If DKA is present:

• Continue IV insulin until DKA resolves (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, pH >7.3) 2
• Provide potassium supplementation when levels are <5.5 mEq/L and renal function is adequate 2
• Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 2
• Monitor for hypokalemia during insulin treatment 3

If hyperglycemia without DKA:

• For critically ill patients: Use continuous IV insulin infusion targeting 140-180 mg/dL 1
• For non-critically ill patients: Consider subcutaneous insulin regimen with basal and bolus components 1
• Avoid exclusive use of sliding-scale insulin regimens, as they are associated with poor glycemic control 4

Transition to Subcutaneous Insulin

Once blood glucose is <200 mg/dL and the patient is stable:

1. Calculate total daily insulin requirement based on IV insulin requirements
2. Divide into basal (50%) and bolus (50%) components
3. Administer first dose of subcutaneous basal insulin 1-2 hours before discontinuing IV insulin 2
4. Continue frequent monitoring during transition

Common Pitfalls to Avoid

1. Hypoglycemia risk:

   • Insulin therapy can cause severe hypoglycemia, which may lead to unconsciousness, seizures, or death 3
   • Monitor glucose frequently during treatment
   • Have glucagon or IV glucose readily available to treat hypoglycemia 1

2. Electrolyte abnormalities:

   • Insulin stimulates potassium movement into cells, potentially causing hypokalemia 3
   • Monitor potassium levels closely, especially when administering IV insulin 3

3. Inadequate monitoring:

   • Failure to adjust antidiabetic medications in response to changes in oral intake is a common cause of glycemic excursions 4
   • Implement a policy requiring staff notification for all blood glucose results outside specified ranges (e.g., <50 or >350 mg/dL) 1

4. Fluid balance issues:

   • Severe hyperglycemia causes osmotic diuresis and dehydration
   • Ensure adequate fluid replacement but monitor for signs of fluid overload, especially in patients with cardiac or renal dysfunction 5

Long-term Management

After acute management:

1. Identify and address the underlying cause of hyperglycemia
2. Provide diabetes education on recognition and prevention of hyperglycemia
3. Establish appropriate follow-up care
4. Consider metformin therapy for type 2 diabetes after resolution of acute hyperglycemia 2

This approach prioritizes immediate treatment of severe hyperglycemia while minimizing the risks of complications, with the goal of improving morbidity and mortality outcomes.