Management of Severe Hyperglycemia with Blood Glucose of 465 mg/dL
For a patient with severe hyperglycemia (blood glucose 465 mg/dL), initiate insulin therapy immediately with a starting dose of basal insulin at 0.1-0.2 units/kg depending on the degree of hyperglycemia, along with rapid-acting insulin for correction. 1
Initial Insulin Regimen
- For patients with marked hyperglycemia (blood glucose ≥250 mg/dL), initiate basal insulin while simultaneously starting metformin if renal function is normal 1
- With blood glucose of 465 mg/dL, consider a starting total daily dose of insulin at 0.3-0.5 units/kg, with approximately half as basal insulin and half as bolus/correction insulin 1
- For a 70kg adult, this would translate to approximately 21-35 units of basal insulin and additional correction doses 1
- In patients with blood glucose >300 mg/dL, especially if symptomatic, a basal-bolus insulin regimen is the preferred initial approach 1
Target Blood Glucose Range
- Aim for a target glucose range of 140-180 mg/dL for most hospitalized patients with hyperglycemia 1
- More stringent goals (110-140 mg/dL) may be appropriate for selected patients if they can be achieved without significant hypoglycemia 1
- Avoid targets less than 70 mg/dL as hypoglycemia increases mortality risk 1, 2
Insulin Titration Protocol
- After initiating insulin, adjust the dose based on blood glucose monitoring results 1
- For basal insulin titration, increase dose by 2-4 units every 3 days if fasting glucose remains elevated 3
- For correction insulin, use a sliding scale based on pre-meal glucose values 1
- Consider a more aggressive correction scale for severe hyperglycemia (BG >400 mg/dL) 1
Monitoring Requirements
- Monitor blood glucose every 4-6 hours initially for non-critically ill patients 1
- For patients on intravenous insulin, more frequent monitoring (every 30 min to 2 hours) is required 1
- Assess for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state, especially with blood glucose >600 mg/dL 1
Special Considerations
- For patients with ketosis/ketoacidosis, initiate subcutaneous or intravenous insulin to rapidly correct hyperglycemia and metabolic derangement 1
- Maintain hydration with non-caloric fluids during treatment of severe hyperglycemia 4
- Never stop insulin during illness, even when not eating, as this is a common cause of DKA 4
Common Pitfalls to Avoid
- Inadequate initial insulin dosing leading to persistent hyperglycemia 5
- Failure to adjust insulin doses based on response 5
- Overaggressive insulin therapy leading to hypoglycemia 1
- Stopping insulin during illness or when not eating 4
- Inadequate hydration during hyperglycemic episodes 4
By following these guidelines, you can effectively manage severe hyperglycemia while minimizing the risk of complications such as hypoglycemia, DKA, or hyperosmolar hyperglycemic state.