What is the protocol for managing Hyperglycemia (high blood sugar)?

From the Guidelines

The hyperglycemia protocol for managing high blood sugar typically begins with identifying blood glucose levels above 180 mg/dL (10 mmol/L) and implementing appropriate interventions, with a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) for the majority of critically ill patients, as recommended by the most recent guidelines 1.

Key Considerations

• Insulin therapy should be initiated for the treatment of persistent hyperglycemia at a blood glucose level of 180 mg/dL (10.0 mmol/L) or higher, with a goal of maintaining blood glucose levels within the target range 1.
• For noncritically ill patients, a target range of 100–180 mg/dL (5.6–10.0 mmol/L) is recommended, with more stringent goals potentially appropriate for selected patients, such as those undergoing cardiac surgery 1.
• Basal-bolus regimens are preferred over sliding scale insulin alone for diabetic patients on regular insulin therapy, as they provide more physiological glucose control and reduce the risk of hypoglycemia 1.

Management Strategies

• For mild hyperglycemia (180-250 mg/dL), administer rapid-acting insulin such as lispro, aspart, or glulisine at 0.1 units/kg or 4-6 units subcutaneously, with rechecking of blood glucose 2-4 hours after insulin administration.
• For moderate hyperglycemia (250-350 mg/dL), give 0.15 units/kg or 6-10 units, and for severe hyperglycemia (>350 mg/dL), administer 0.2 units/kg or 10-15 units.
• For hospitalized patients, an insulin infusion may be initiated at 0.05-0.1 units/kg/hour for glucose levels persistently above 180 mg/dL, with hourly glucose monitoring and adjustment according to a standardized protocol 1.

Additional Recommendations

• Ensure adequate hydration with IV fluids if needed, particularly in patients with significant hyperglycemia.
• Addressing the underlying cause of hyperglycemia, such as infection, medication effects, or inadequate baseline diabetes management, is essential for effective long-term control.
• A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system, with a plan for preventing and treating hypoglycemia established for each patient 1.

From the FDA Drug Label

Hyperglycemia (High Blood Sugar) and Diabetic Ketoacidosis (DKA) Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. Eating significantly more than your meal plan suggests. Developing a fever, infection, or other significant stressful situation. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency)

The protocol for managing Hyperglycemia (high blood sugar) is not explicitly stated in the provided text, but the text does mention that Hyperglycemia can be caused by omitting insulin, eating more than the meal plan suggests, or developing a fever or infection. It also states that prolonged Hyperglycemia can lead to Diabetic Ketoacidosis (DKA), a life-threatening emergency.

• Key points to consider in managing Hyperglycemia include:
  • Taking insulin as prescribed by the doctor
  • Following the meal plan
  • Monitoring for signs of Hyperglycemia and DKA, such as a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath
  • Obtaining medical assistance immediately if symptoms of Hyperglycemia or DKA occur 2

From the Research

Protocol for Managing Hyperglycemia

The protocol for managing hyperglycemia involves several key components, including:

• Identifying and treating hyperglycemia in hospitalized patients to prevent complications and reduce morbidity and mortality 3
• Using intravenous (IV) insulin in critically ill patients, with a starting threshold no higher than 180 mg/dL and maintaining glucose levels between 140 and 180 mg/dL 4
• Implementing basal-bolus regimens with basal, prandial, and correction components for noncritically ill patients with good nutritional intake 4
• Using a single dose of long-acting insulin plus correction insulin for patients with poor or no oral intake 4
• Measuring hemoglobin A1c at admission to assess glycemic control and tailor the treatment regimen at discharge 4

Target Blood Glucose Values

Target blood glucose values are an important aspect of managing hyperglycemia, with recommendations including:

• Maintaining glucose levels between 140 and 180 mg/dL in critically ill patients 4
• Targeting blood glucose levels consistent with current recommendations, rather than inconsistent levels 5
• Monitoring and managing postprandial hyperglycemia, which is an independent risk factor for cardiovascular disease 6

Barriers to Better Care

Barriers to better care for managing hyperglycemia include:

• Unpredictable changes in patient diet and mealtimes 5
• Risk of causing patient hypoglycemia 5
• Lack of knowledge about insulin types and pharmacokinetics among residents 5
• Unfamiliarity with ordering prandial and basal insulin 5

Treatment Options

Treatment options for managing hyperglycemia include:

• Insulin therapy, including IV insulin, basal-bolus regimens, and long-acting insulin 4, 5
• Glucagon-like peptide-1 (GLP-1) receptor agonists, which target the GLP-1 hormone to improve glucose-dependent insulin release and suppress glucagon release 7
• Other therapies, such as metformin, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sulfonylureas 7