How do I manage non-acidotic hyperglycemia (elevated blood glucose) in the Emergency Room (ER)?

Management of Non-Acidotic Hyperglycemia in the Emergency Room

For non-acidotic hyperglycemia in the ER, insulin therapy should be initiated when glucose levels are persistently ≥180 mg/dL, with a target glucose range of 140-180 mg/dL for most patients. 1, 2

Initial Assessment

• Immediately check blood glucose levels to confirm hyperglycemia (>140 mg/dL or >7.8 mmol/L) 3
• Assess for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) through laboratory tests including electrolytes, anion gap, and ketones 3
• Identify and address any precipitating factors such as infection, myocardial infarction, or stroke 3
• Consider measuring HbA1c at admission to assess baseline glycemic control and to guide treatment decisions 4

Treatment Algorithm for Non-Acidotic Hyperglycemia

For Critically Ill Patients:

• Use intravenous insulin infusion with a starting threshold of no higher than 180 mg/dL 1
• Maintain glucose levels between 140-180 mg/dL once IV insulin is started 1, 5
• Use validated written or computerized protocols for IV insulin administration that allow for predefined adjustments in infusion rate 1
• Consider lower glucose targets (120-140 mg/dL) for select patients such as cardiac surgery patients if achievable without significant hypoglycemia 1, 3
• Avoid targets <110 mg/dL due to increased risk of hypoglycemia 1, 5

For Non-Critically Ill Patients:

• For patients with good nutritional intake: Use a basal-bolus insulin regimen with basal, nutritional, and correction components 1
• For patients with poor or no oral intake: Use a basal plus correction insulin regimen 1
• Target premeal glucose levels <140 mg/dL and random blood glucose <180 mg/dL 1
• Strongly avoid using sliding-scale insulin as the sole method of treatment 1
• Perform point-of-care glucose testing immediately before meals for patients who are eating 1
• Monitor every 4-6 hours for patients who are not eating 3

Transitioning from IV to Subcutaneous Insulin

• When discontinuing IV insulin therapy, start subcutaneous insulin 1-2 hours before stopping the IV infusion 1
• Convert to basal insulin at 60-80% of the daily IV infusion dose 1
• For calculating subcutaneous insulin dose from IV insulin:
  • Use 1/2 of the total amount of insulin infused in 24 hours as the dose of slow-acting insulin (given once in the evening) 1
  • Divide the other 1/2 by 3 to determine the dose of ultra-rapid analogue insulin per meal 1

Special Considerations

• For pre-prandial glucose ≥16.5 mmol/L (300 mg/dL) without ketosis: Give 6 IU ultra-rapid analogue insulin subcutaneously and recheck glucose 3 hours later 1
• For pre-prandial glucose ≥16.5 mmol/L with ketosis: Consider transfer to ICU for IV insulin therapy if ketonemia ≥1.5 mmol/L 1
• For stress hyperglycemia (elevated blood glucose with HbA1c <6.5%): Insulin can be stopped progressively as blood glucose normalizes 1
• Reassess insulin regimen if blood glucose falls below 100 mg/dL to avoid hypoglycemia 1
• Modify regimen when blood glucose values are <70 mg/dL unless easily explained by factors such as missed meals 1

Common Pitfalls and How to Avoid Them

• Avoid sole use of sliding-scale insulin as it is strongly discouraged and associated with poor outcomes 1
• Prevent hypoglycemia by frequent monitoring and appropriate adjustment of insulin doses 1, 6
• Be aware that overaggressive glucose lowering (targeting <110 mg/dL) increases risk of hypoglycemia and associated mortality 2, 5
• Recognize that insulin requirements may be increased with certain medications (oral contraceptives, corticosteroids, thyroid replacement therapy) 6
• Insulin requirements may be reduced with medications that lower blood glucose (oral antidiabetic agents, salicylates, sulfa antibiotics) 6
• For patients transitioning from IV to subcutaneous insulin, ensure overlap to prevent rebound hyperglycemia 1, 3

By following this structured approach to managing non-acidotic hyperglycemia in the ER, you can effectively control blood glucose levels while minimizing the risk of complications such as hypoglycemia, ultimately improving patient outcomes.