What is the management plan for an inpatient with hyperglycemia (Random Blood Sugar (RBS) level of 22)?

Management of Inpatient Hyperglycemia (RBS = 22)

For an inpatient with hyperglycemia (RBS = 22 mmol/L or approximately 396 mg/dL), immediate insulin therapy is required, with a target glucose range of 7.8-10.0 mmol/L (140-180 mg/dL) for most hospitalized patients. 1

Initial Assessment and Management

• Confirm hyperglycemia with laboratory testing and assess for potential causes (infection, medications, stress) 2
• Check for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) through laboratory tests including electrolytes, anion gap, and ketones 2
• For critically ill patients, initiate continuous intravenous insulin infusion when glucose exceeds 10.0 mmol/L (180 mg/dL) 1
• For non-critically ill patients, use subcutaneous insulin with a basal-bolus regimen 1
• Monitor blood glucose levels frequently - every 1-2 hours initially until stable, then before meals for patients who are eating or every 4-6 hours for those not eating 1

Insulin Regimen Selection

For Critically Ill Patients:

• Use continuous intravenous insulin infusion with validated protocols allowing predefined adjustments based on glucose fluctuations 1
• Target glucose range: 7.8-10.0 mmol/L (140-180 mg/dL) 1
• More stringent goals (6.1-7.8 mmol/L or 110-140 mg/dL) may be appropriate for select patients (e.g., cardiac surgery) if achievable without significant hypoglycemia 1

For Non-Critically Ill Patients:

• For patients with good nutritional intake: Use basal-bolus insulin regimen with three components 1:

  • Basal insulin (long-acting): 0.1-0.25 units/kg/day 1
  • Prandial insulin (rapid-acting): 0.1-0.15 units/kg/meal 1
  • Correction insulin for hyperglycemia 1

• For patients with poor or no oral intake: Use basal insulin plus correction insulin 1

  • Basal insulin: 0.1-0.25 units/kg/day 1
  • Correction insulin as needed 1

• Avoid using sliding scale insulin alone as it results in undesirable glycemic control and increased risk of complications 1

Medication Selection

• Insulin analogs are preferred over human insulin due to lower hypoglycemia risk 3:

  • Long-acting analogs (glargine, detemir) for basal component 3
  • Rapid-acting analogs (aspart, lispro, glulisine) for prandial and correction doses 4, 3

• For intravenous insulin infusion, insulin aspart can be used at concentrations of 0.05-1 unit/mL in 0.9% sodium chloride 4

Monitoring and Adjustment

• For patients on IV insulin: Monitor glucose every 30 minutes to 2 hours 1, 2
• For patients on subcutaneous insulin: Monitor before meals and at bedtime for those eating; every 4-6 hours for those not eating 1
• Adjust insulin doses daily based on blood glucose patterns 1
• Watch for hypoglycemia (blood glucose <3.9 mmol/L or <70 mg/dL), which is associated with increased mortality 1

Special Considerations

• For patients with type 1 diabetes, always maintain basal insulin even when fasting to prevent ketoacidosis 1
• Consider higher glucose targets (up to 11.1 mmol/L or 200 mg/dL) for terminally ill patients or those with severe comorbidities 1
• When transitioning from IV to subcutaneous insulin, administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 2

Common Pitfalls to Avoid

• Using sliding scale insulin alone without basal insulin 1
• Targeting overly tight glycemic control (<6.1 mmol/L or <110 mg/dL), which increases mortality risk 1, 5
• Failing to adjust insulin doses based on changing clinical status, nutritional intake, or medication changes 4
• Discontinuing basal insulin in patients with type 1 diabetes, even when fasting 1
• Neglecting to monitor for hypoglycemia, which can increase mortality 1

Remember that hyperglycemia management requires a structured approach with appropriate insulin regimens and frequent monitoring to achieve target glucose levels while avoiding hypoglycemia 6, 7.