How to manage a patient with severe hyperglycemia?

Management of Severe Hyperglycemia (HGT 540)

For a patient with severe hyperglycemia (HGT 540), immediate intravenous insulin therapy should be initiated with an initial IV bolus of regular insulin at 0.15 units/kg body weight, followed by continuous infusion at 0.1 unit/kg/hour (typically 5-7 units/hour). 1

Initial Assessment and Monitoring

1. Check for ketones immediately

   • Rule out diabetic ketoacidosis (DKA)
   • Ketonuria 2+ or ketonemia ≥1.5 mmol/L indicates need for ICU transfer 1
   • Assess mental status to identify complications

2. Monitoring frequency

   • Monitor blood glucose hourly until stable
   • Then every 2-4 hours once stabilized 1
   • Monitor electrolytes, especially potassium, every 2-4 hours 1

Treatment Protocol

For Critically Ill Patients or Severe Hyperglycemia

1. Intravenous Insulin Therapy

   • Start continuous IV regular insulin infusion with initial bolus of 0.15 units/kg 1
   • Continue infusion at 0.1 unit/kg/hour 1
   • Use validated written or computerized protocols for insulin dosage adjustments 2
   • Target blood glucose range: 140-180 mg/dL 2

2. Fluid Management

   • Initiate 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

3. Electrolyte Management

   • Add 20-40 mEq/L potassium to IV fluids once renal function is confirmed and serum potassium is known 1
   • Monitor for hypokalemia which is common (about 50%) during treatment 2

For Non-Critically Ill Patients with Hyperglycemia

If the patient is stable without signs of DKA or hyperosmolar state:

1. Insulin Regimen

   • Implement a basal-bolus correction insulin regimen 2, 1
   • 50% of total daily dose as basal insulin and 50% as prandial insulin divided between meals 1
   • Avoid using sliding scale insulin alone (often called "sliding scale") as it is ineffective 2, 1

2. Dosing Guidelines

   • 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
   • Target pre-meal glucose levels below 140 mg/dL and random glucose levels below 180 mg/dL 1

Transitioning from IV to Subcutaneous Insulin

1. Calculate Total Daily Dose (TDD)

   • Base TDD on the average insulin infusion rate over the previous 12 hours 1
   • Convert to basal insulin at 60-80% of the daily infusion dose 1

2. Timing

   • Administer subcutaneous insulin 1-2 hours before discontinuing IV insulin 1
   • Implement a basal-bolus regimen (not sliding scale alone) 2, 1

Avoiding Common Pitfalls

1. Never rely solely on sliding scale insulin

   • This approach treats hyperglycemia after it occurs rather than preventing it 2, 1
   • Use scheduled insulin orders with basal, prandial, and correction components 2

2. Always check for ketoacidosis

   • Neglecting to monitor for ketoacidosis can lead to delayed diagnosis and treatment 1
   • In patients with T1D and insulin-treated T2D with glucose >16.5 mmol/L (3 g/L), check for ketosis 2

3. Prevent hypoglycemia

   • Adopt a hypoglycemia management protocol 2
   • Review and change treatment regimens when blood glucose <70 mg/dL (3.9 mmol/L) is documented 2

4. Proper transition from IV to subcutaneous insulin

   • Improper transition can lead to rebound hyperglycemia 1
   • Ensure overlap between IV insulin discontinuation and subcutaneous insulin administration 1

Follow-up

1. Arrange follow-up within 1-4 weeks after discharge 1

2. Consider referral to a diabetes specialist for patients with:

   • HbA1c > 9%
   • Unstable blood sugar levels (>2 g/L or 11 mmol/L) 1

3. Before discharge:

   • If oral medications were held during hospitalization, resume them 1-2 days before discharge 2
   • Ensure patient understands their diabetes management plan