What is the treatment for severe hyperglycemia?

Management of Severe Hyperglycemia (Blood Sugar 400 mg/dL)

For a blood glucose level of 400 mg/dL, immediate treatment with intravenous insulin infusion is required, targeting a glucose range of 140-180 mg/dL (7.8-10.0 mmol/L). 1

Immediate Management

Initial Assessment

• Evaluate for symptoms of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS):
  • Mental status changes
  • Dehydration
  • Fruity breath odor (in DKA)
  • Nausea/vomiting
  • Abdominal pain

Intravenous Insulin Therapy

• Start continuous IV insulin infusion at an appropriate rate based on current glucose level 1
• Monitor glucose levels hourly until stable, then every 2 hours
• Target glucose range: 140-180 mg/dL (7.8-10.0 mmol/L) 2, 1

Fluid Replacement

• Begin IV fluid resuscitation with normal saline to correct hypovolemia 1
• Initial rate: 15-20 mL/kg/hour if no cardiac or renal contraindications
• Adjust based on hemodynamic status and electrolyte levels

Electrolyte Management

• Monitor potassium levels closely - hypokalemia is common during insulin treatment 1, 3
• Replace potassium if levels are low or normal (but expected to fall with insulin therapy)
• Monitor for other electrolyte abnormalities (sodium, phosphate, magnesium)

Transition to Subcutaneous Insulin

Once the patient is stabilized (glucose <250 mg/dL, metabolically stable):

1. Start subcutaneous basal insulin 2-4 hours before discontinuing IV insulin 1
2. Implement a basal-bolus insulin regimen rather than sliding scale 1
3. Distribute insulin as approximately 50% basal and 50% prandial 1

Special Considerations

For Type 1 Diabetes

• Never discontinue basal insulin completely due to risk of ketoacidosis 2
• Patients require both basal and prandial insulin components 2

For Type 2 Diabetes

• Consider initial combination therapy, especially with HbA1c >8.5% 2
• Once stabilized, GLP-1 receptor agonists should be considered before initiating long-term insulin therapy if no contraindications exist 2

For Hospitalized Patients

• For critically ill patients: maintain glucose between 140-180 mg/dL with IV insulin infusion 2
• For non-critically ill patients: target pre-meal glucose <140 mg/dL and random glucose <180 mg/dL 2

Monitoring and Complications Prevention

Hypoglycemia Prevention

• Monitor for symptoms of hypoglycemia (glucose <70 mg/dL): sweating, tremors, confusion, anxiety 3
• Have quick-acting glucose sources available (glucose tablets, juice)
• Modify insulin regimen if glucose falls below 100 mg/dL 2

Hyperglycemia Monitoring

• Check glucose levels frequently during initial management
• Implement a consistent carbohydrate meal plan 1
• Adjust insulin doses every 2-3 days based on glucose patterns 1

Long-term Management

After acute management:

1. Identify and address the cause of severe hyperglycemia
2. Provide diabetes self-management education
3. Consider consultation with endocrinology for complex cases
4. Establish appropriate follow-up care and monitoring

Clinical Pearls

• Stress hyperglycemia in critically ill patients is associated with higher mortality (31%) compared to patients with known diabetes (10%) 4
• Glycemic variability (difference between maximum and minimum glucose) is a strong predictor of adverse outcomes 4
• Even brief periods of hyperglycemia increase the risk of complications 5
• Hyperglycemia itself can contribute to insulin resistance, creating a vicious cycle 6

Remember that severe hyperglycemia (>400 mg/dL) is a medical emergency that requires prompt intervention to prevent life-threatening complications such as DKA or HHS.