Management of Inpatient with Blood Glucose of 300 mg/dL and Uncontrolled Diabetes Mellitus
For an inpatient with uncontrolled diabetes mellitus and a blood glucose of 300 mg/dL, a basal-bolus insulin regimen should be initiated immediately to effectively reduce hyperglycemia and prevent complications.
Initial Assessment and Treatment Strategy
- For patients with severe hyperglycemia (>300 mg/dL), a basal-bolus insulin regimen is indicated as the most appropriate treatment approach 1
- Target glucose levels for most hospitalized patients should be between 140-180 mg/dL (7.8-10.0 mmol/L) to balance glycemic control while minimizing hypoglycemia risk 1
- Insulin remains the agent of choice for patients with severe hyperglycemia, those on high doses of insulin at home, type 1 diabetes, or steroid-induced hyperglycemia 1
Insulin Regimen Implementation
For Severe Hyperglycemia (>300 mg/dL):
- Start with a basal-bolus insulin regimen, reducing home insulin total daily dose (TDD) by 20% or starting at 0.3 units/kg/day 1
- Distribute the total daily dose as 50% basal insulin and 50% bolus (prandial) insulin 1, 2
- For insulin-naive patients with severe hyperglycemia, calculate initial insulin dose as 0.3-0.5 units/kg/day 2
- Adjust insulin doses every 3-4 days until target blood glucose levels are reached 3
Practical Administration:
- Administer insulin using validated written or computerized protocols that allow for predefined adjustments based on glycemic fluctuations 1
- Withhold prandial insulin if oral intake is poor, following hospital regulations 1
- Monitor blood glucose before meals and at bedtime, with additional checks if clinically indicated 1
Special Considerations
- For patients with renal impairment, insulin requirements may need adjustment due to altered metabolism and clearance 4
- Start with lower insulin doses (approximately 75% of standard starting dose) in patients with renal impairment to reduce hypoglycemia risk 2
- Monitor for hypoglycemia, which is the most common adverse effect of insulin therapy 4
- Early warning symptoms of hypoglycemia may be different or less pronounced in patients with long-duration diabetes, diabetic neuropathy, or those on beta-blockers 4
Monitoring and Adjustment
- Monitor blood glucose levels frequently during insulin dose adjustment 2
- Adjust basal insulin by 2 units every 3-4 days until fasting glucose reaches target 2
- Adjust prandial insulin based on pre-meal glucose levels and carbohydrate content of meals 2
- For patients with persistent hyperglycemia despite initial therapy, consider increasing insulin doses or adding additional insulin components 1
Discharge Planning
- For patients with uncontrolled diabetes being discharged, consider a combination of oral antidiabetes drugs with basal insulin or a basal-bolus insulin regimen at 80% of inpatient dose 1
- Provide diabetes self-management education including understanding of diagnosis, glucose monitoring, medication administration, and sick day management 1
- Discuss medication costs and insurance coverage to ensure treatment adherence after discharge 1
Common Pitfalls to Avoid
- Delaying insulin intensification in patients with severe hyperglycemia can lead to prolonged hyperglycemia and increased complications 5
- Using sliding scale insulin alone without basal insulin is ineffective for controlling severe hyperglycemia 1
- Targeting overly strict glycemic control (<140 mg/dL) increases risk of hypoglycemia without providing additional benefits 6
- Failing to adjust insulin doses for patients with renal impairment can lead to severe hypoglycemia 4
By following this structured approach to managing inpatient hyperglycemia, clinicians can effectively control blood glucose levels while minimizing the risks of hypoglycemia and other complications.