What is the appropriate treatment for a diabetic patient with hyperglycemia (elevated blood sugar) over 500 mg/dL?

Management of Diabetic Patients with Blood Sugar Over 500 mg/dL

For diabetic patients with blood sugar over 500 mg/dL, immediate hospitalization and intravenous insulin therapy is required, with an initial IV bolus of regular insulin at 0.15 units/kg followed by continuous infusion at 0.1 unit/kg/hour. 1

Initial Management

Immediate Interventions

• Start continuous intravenous regular insulin:
  • Adult patients: Initial IV bolus of regular insulin at 0.15 units/kg, followed by continuous infusion at 0.1 unit/kg/hour (typically 5-7 units/hour) 1
  • Pediatric patients: Start continuous IV insulin without bolus at 0.1 unit/kg/hour 1

Fluid Replacement

• Begin aggressive fluid replacement with isotonic saline (0.9% NaCl) at 10-20 mL/kg/hour for the first hour 1
• Initial rehydration should not exceed 50 mL/kg over the first 4 hours 1
• After initial rehydration, switch to 0.45-0.9% NaCl depending on serum sodium 1

Electrolyte Management

• Monitor electrolytes, especially potassium, every 2-4 hours 1
• Once renal function is confirmed and serum potassium is known, add 20-40 mEq/L potassium to IV fluids 1

Monitoring During Treatment

• Target glucose range: 140-180 mg/dL for most hospitalized patients 1
• Monitor blood glucose hourly until stable, then every 2-4 hours 1
• Assess mental status regularly to identify complications 1
• Check for ketones to rule out diabetic ketoacidosis (DKA) 2
  • If ketones are present (ketonuria 2+ or ketonemia ≥1.5 mmol/L), transfer to ICU for IV insulin therapy 2

Transition to Subcutaneous Insulin

Once glucose levels stabilize (typically <250 mg/dL):

1. Calculate Total Daily Dose (TDD) based on average insulin infusion rate over previous 12 hours 1
2. Give subcutaneous insulin 1-2 hours before discontinuing IV insulin 1
3. Convert to basal insulin at 60-80% of the daily infusion dose 1
4. Implement a basal-bolus regimen (not sliding scale alone) 2, 1
   • 50% as basal insulin
   • 50% as prandial insulin divided between meals 1

Ongoing Management

Insulin Regimen

• Avoid using only sliding scale insulin as it is strongly discouraged and ineffective 2, 1
• Use a basal-bolus correction insulin regimen for non-critically ill hospitalized patients 2
• Start prandial insulin with 4-6 units of rapid-acting insulin before each meal 1
• Adjust basal insulin by 2-4 units every 1-3 days until fasting glucose reaches target range 1

Blood Glucose Monitoring

• Monitor blood glucose before meals and at bedtime 1
• For patients not eating, monitor every 4-6 hours 2, 1
• Target pre-meal glucose levels below 140 mg/dL and random glucose levels below 180 mg/dL 1

Special Considerations

Type 1 vs. Type 2 Diabetes

• Type 1 diabetes: Always requires insulin therapy; never discontinue insulin 2
• Type 2 diabetes: May resume oral medications after stabilization if appropriate 2

Outpatient Follow-up Planning

• Arrange follow-up within 1-4 weeks after discharge 2
• Consider referral to diabetes specialist or endocrinologist for patients with:
  • HbA1c > 9% 2
  • Unstable blood sugar levels (>2 g/L or 11 mmol/L) 2

Common Pitfalls to Avoid

1. Relying solely on sliding scale insulin - This reactive approach treats hyperglycemia after it occurs rather than preventing it 2, 1

2. Improper transition from IV to subcutaneous insulin - Can lead to rebound hyperglycemia if overlap is insufficient 1

3. Inadequate total insulin dose - Failure to adjust both basal and bolus components leads to poor glucose control 1

4. Too rapid correction of glucose - May lead to cerebral edema, especially in pediatric patients 1

5. Neglecting to monitor for ketoacidosis - Always check for ketones in patients with severe hyperglycemia 2