What is the management for a patient with hyperglycemia?

Management of Hyperglycemia (Blood Glucose 12 mmol/L)

For patients with a venous blood glucose of 12 mmol/L (216 mg/dL), immediate treatment with insulin therapy is recommended, with the specific regimen determined by the clinical setting (critical vs. non-critical care) and the patient's nutritional status.

Initial Assessment and Management

• Assess for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) through laboratory tests including electrolytes, anion gap, and ketones 1
• Identify and address any precipitating factors such as infection, myocardial infarction, stroke, or other stressors 1
• For patients who are eating, point-of-care glucose monitoring should be performed before meals; for those not eating, monitor every 4-6 hours 2, 1
• More frequent monitoring (every 30 minutes to 2 hours) is required when using intravenous insulin 2

Management in Critical Care Settings

• Continuous intravenous insulin infusion is the most effective method for achieving glycemic targets in critically ill patients 2
• Initiate intravenous insulin therapy when glucose is ≥180 mg/dL (10.0 mmol/L), with a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) 1
• Administer intravenous insulin based on validated written or computerized protocols that allow for predefined adjustments in infusion rate 2
• More stringent goals (110-140 mg/dL) may be appropriate for selected patients (e.g., cardiac surgery patients) if achievable without significant hypoglycemia 2, 1

Management in Non-Critical Care Settings

• For most non-critically ill hospitalized patients, subcutaneous insulin is the preferred treatment for hyperglycemia 2
• Use a regimen with basal, prandial, and correction components for patients with good nutritional intake 2
• For patients with poor or no oral intake, use basal insulin plus correction insulin 2
• Avoid using sliding scale insulin as the sole regimen, as it results in undesirable glycemic fluctuations and increased risk of hospital complications 2

Specific Insulin Regimens

• For patients with adequate oral intake, use a basal-bolus regimen divided as half basal and half prandial insulin, starting at a total daily dose of 0.3 units per kg 2
• Basal insulin (such as insulin detemir) provides background insulin coverage 3
• Rapid-acting insulin (such as insulin lispro) before meals helps control postprandial hyperglycemia 4
• For patients with type 1 diabetes, dosing insulin based solely on premeal glucose levels does not account for basal insulin requirements, increasing the risk of both hypoglycemia and hyperglycemia 2

Prevention and Management of Hypoglycemia

• Implement a hypoglycemia management protocol for each patient 2
• Review and change treatment regimens when blood glucose <70 mg/dL (3.9 mmol/L) is documented 2
• Glucose (15-20g) is the preferred treatment for conscious individuals with hypoglycemia 2
• If hypoglycemia persists after 15 minutes, repeat the treatment 2
• Once blood glucose returns to normal, the patient should consume a meal or snack to prevent recurrence 2
• Glucagon should be prescribed for patients at significant risk of severe hypoglycemia 2

Special Considerations

• For patients with intercurrent illness, more frequent monitoring of blood glucose is necessary 2
• Marked hyperglycemia during illness may require temporary adjustment of the treatment program 2
• If ketosis, vomiting, or altered consciousness is present, immediate interaction with the diabetes care team is required 2
• Patients treated with non-insulin therapies may temporarily require insulin during acute illness 2
• Ensure adequate fluid and caloric intake during illness 2

Transition Planning and Discharge

• If oral medications are held in the hospital but will be reinstated after discharge, implement a protocol for resuming home medications 1-2 days prior to discharge 2
• Measure hemoglobin A1c at admission to assess glycemic control and tailor the treatment regimen at discharge 5
• For patients transitioning from IV to subcutaneous insulin, administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1

Important Caveats

• Avoid intensive glycemic control with targets <110 mg/dL as it has been associated with increased mortality compared to more moderate targets (140-180 mg/dL) 1
• Consider patient-specific factors when setting glycemic targets, especially in elderly patients or those with frailty 2
• Hypoglycemia can cause acute harm and is associated with increased mortality, making prevention crucial 2
• Chronic hyperglycemia contributes to both microvascular and macrovascular complications, emphasizing the importance of achieving good glycemic control 6, 7