How to manage severe hyperglycemia?

Management of Severe Hyperglycemia (Blood Glucose 515 mg/dL)

For a blood glucose of 515 mg/dL, immediate treatment with intravenous insulin is recommended to rapidly correct hyperglycemia and prevent metabolic decompensation. 1

Initial Assessment and Management

• Evaluate for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), including mental status changes, dehydration, fruity breath odor, abdominal pain, nausea/vomiting, and ketones in urine or blood 1, 2
• Check for precipitating factors: infection, myocardial infarction, stroke, medication non-adherence, or new-onset diabetes 1, 3
• Assess fluid status and electrolytes, particularly potassium, as hyperkalemia is common in severe hyperglycemia, especially with ketoacidosis 1, 4
• Obtain laboratory tests including complete metabolic panel, serum ketones, arterial blood gas (if DKA suspected), and urinalysis 1

Treatment Algorithm

For Critically Ill Patients:

• Initiate continuous intravenous insulin infusion 1
• Target glucose range of 140-180 mg/dL for most patients 1
• Monitor blood glucose every 30 minutes to 2 hours until stable, then every 4 hours 1, 5
• Provide adequate fluid resuscitation to restore circulatory volume and tissue perfusion 1
• Correct electrolyte imbalances, particularly potassium 1, 4

For Non-Critically Ill Patients with DKA or HHS:

• Intravenous insulin is the standard of care for DKA/HHS 1
• Successful transition from IV to subcutaneous insulin requires administration of basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1
• Mild to moderate DKA may be treated with subcutaneous rapid-acting insulin analogs in combination with aggressive fluid management in appropriate settings 1

For Non-Critically Ill Patients without DKA/HHS:

• Insulin therapy should be initiated for persistent hyperglycemia ≥180 mg/dL 1
• For markedly elevated glucose (≥250 mg/dL) with symptoms (polyuria, polydipsia, nocturia, weight loss), start basal insulin while initiating metformin 1
• For severe hyperglycemia (≥600 mg/dL), assess for hyperosmolar hyperglycemic state 1
• Use scheduled subcutaneous basal-bolus insulin regimens rather than sliding scale insulin alone 1

Special Considerations

• In patients with type 1 diabetes or insulin-deficient type 2 diabetes, prolonged hyperglycemia can result in DKA, which is life-threatening 2
• For patients with AMI and hyperglycemia, maintain glucose <180 mg/dL to improve outcomes 6
• Avoid bicarbonate use in DKA as studies show no benefit in resolution of acidosis 1
• For patients on dialysis with hyperglycemia, insulin infusion is the primary management strategy 4

Transition of Care

• Develop a structured discharge plan tailored to the individual patient 1
• Transition from IV to subcutaneous insulin requires overlap of 2-4 hours to prevent rebound hyperglycemia 1
• For patients initially treated with insulin and metformin who meet glucose targets, insulin can be tapered over 2-6 weeks by decreasing the dose 10-30% every few days 1

Monitoring and Follow-up

• Monitor for hypoglycemia, which is a common complication of insulin treatment 2, 4
• Set threshold alarms for glucose monitoring (e.g., <90 mg/dL for hypoglycemia risk and >150 mg/dL for hyperglycemia) to improve safety 5
• Schedule follow-up within 1-2 weeks to reassess glycemic control and adjust therapy as needed 1

Prevention of Recurrence

• Address underlying causes of hyperglycemia 3
• Provide diabetes self-management education 1
• Consider combination therapy for patients with high A1C at diagnosis (>8.5%) to achieve more rapid glycemic control 1

Remember that severe hyperglycemia is a medical emergency that requires prompt intervention to prevent serious complications including DKA, HHS, and death 2, 1.