What is the management plan for a patient with severe hyperglycemia (elevated blood sugar level)?

Management of Severe Hyperglycemia (Blood Sugar 280 mg/dL)

Immediate insulin therapy should be initiated for this patient with a blood glucose of 280 mg/dL to prevent complications and reduce morbidity and mortality. 1, 2

Initial Assessment and Management

• Severe hyperglycemia (280 mg/dL) requires prompt intervention to prevent progression to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state, which are life-threatening conditions 1
• Check for ketones in urine or blood to assess for ketosis, which would indicate more urgent treatment needs 2
• Evaluate for symptoms of polyuria, polydipsia, or unexpected weight loss that may indicate catabolic state 1
• Assess for potential causes of hyperglycemia including:
  • Intercurrent illness or infection 1
  • Missed or inadequate medication 1
  • Corticosteroid therapy or other diabetogenic medications 3

Treatment Algorithm

For Non-Critical Outpatient Management:

1. Insulin Therapy:

   • For blood glucose >250 mg/dL, rapid-acting insulin (like insulin aspart) should be administered subcutaneously 4
   • Initial dose: 0.1 units/kg body weight 2
   • Inject subcutaneously within 5-10 minutes before meals into the abdominal area, thigh, buttocks, or upper arm 4

2. Fluid Management:

   • Ensure adequate oral fluid intake to prevent dehydration 1, 2
   • If unable to maintain oral hydration or showing signs of dehydration, consider IV fluid therapy 2

3. Monitoring:

   • Check blood glucose every 4-6 hours until stable 1
   • Continue to monitor for ketones if initially present 2

For Hospital/Emergency Management:

1. Insulin Therapy:

   • For blood glucose >250 mg/dL with ketosis, initiate IV insulin at 0.1 units/kg/hour 2
   • Target glucose range of 140-180 mg/dL for most patients 1
   • Continue insulin therapy until ketosis resolves, even after blood glucose normalizes 2

2. Fluid Therapy:

   • Begin with isotonic saline to restore intravascular volume 2
   • Switch to 5% dextrose with 0.45-0.75% NaCl once blood glucose reaches 250 mg/dL to prevent hypoglycemia while continuing insulin therapy 2

3. Electrolyte Monitoring and Replacement:

   • Check electrolytes, especially potassium, every 2-4 hours initially 2
   • Monitor acid-base status via venous pH and anion gap if DKA is suspected 2

Long-term Management

• After acute management, transition to a multiple-dose insulin regimen with combination of short/rapid-acting and intermediate/long-acting insulin 2
• For patients with type 2 diabetes, consider adding metformin as first-line therapy once acute hyperglycemia is controlled 1
• When A1C is ≥1.5% above the individualized glycemic goal, many individuals will require dual-combination therapy 1
• Target A1C <7.0% for most adults with diabetes 1
• More stringent goals (A1C <6%) can be considered in individual patients without risk of hypoglycemia 1

Special Considerations

• Infection or dehydration is more likely to necessitate hospitalization in people with diabetes than those without diabetes 1
• The stress of illness frequently aggravates glycemic control and may precipitate diabetic ketoacidosis or hyperosmolar state 1
• Aggressive glycemic management with insulin may reduce morbidity in patients with severe acute illness 1
• Patients with type 1 diabetes who are at risk for DKA should be identified, particularly those with a prior history of frequent DKA episodes 1

Common Pitfalls to Avoid

• Never delay insulin therapy in patients with significant hyperglycemia and ketosis 2
• Don't stop insulin therapy prematurely when glucose normalizes but ketosis persists 2
• Avoid rapid correction of glucose to prevent complications 2
• Be aware that repeated insulin injections into areas of lipodystrophy can result in hyperglycemia 4
• Remember that even brief periods of hyperglycemia increase the risk of microvascular and macrovascular complications 5, 6

By following this management approach, you can effectively address severe hyperglycemia, prevent complications, and improve patient outcomes.