What is the treatment for a patient presenting to the Emergency Room (ER) with hyperglycemia?

Management of Blood Glucose 15 mmol/L (270 mg/dL) in the Emergency Room

Initiate insulin therapy immediately for this patient with severe hyperglycemia to prevent progression to life-threatening complications such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state. 1

Immediate Assessment

Before starting treatment, rapidly evaluate the following critical parameters:

• Check for ketones in urine or blood to assess for ketosis, which indicates more urgent treatment needs and potential DKA 1
• Assess clinical severity: Look for symptoms of DKA including drowsy feeling, flushed face, thirst, loss of appetite, fruity odor on breath, heavy breathing, rapid pulse, nausea, vomiting, or altered mental status 2
• Identify precipitating factors: Evaluate for infection, missed insulin doses, inadequate medication, or other acute illness 1
• Determine hydration status: Assess for signs of dehydration including poor skin turgor, dry mucous membranes, and hemodynamic instability 1

Treatment Algorithm Based on Clinical Presentation

If Ketones Present or DKA Suspected:

• Start IV insulin infusion immediately at 0.1 units/kg/hour for blood glucose >250 mg/dL with ketosis 1
• Begin fluid resuscitation with isotonic saline to restore intravascular volume 1
• Target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) for most patients 3
• Switch to 5% dextrose with 0.45-0.75% NaCl once blood glucose reaches 250 mg/dL to prevent hypoglycemia while continuing insulin therapy 1
• Monitor blood glucose every 1-2 hours during IV insulin infusion 3

If No Ketones and Patient Stable:

• Administer rapid-acting insulin subcutaneously at initial dose of 0.1 units/kg body weight 1
• Ensure adequate oral fluid intake to prevent dehydration; consider IV fluids if oral hydration inadequate 1
• Monitor blood glucose every 4-6 hours until stable 3, 1
• Target premeal glucose <140 mg/dL and random glucose <180 mg/dL for noncritically ill patients 3

Critical Care vs. Non-Critical Care Decision

Admit to ICU if:

• Patient has altered mental status, severe dehydration, or hemodynamic instability 4
• DKA or hyperosmolar state is confirmed 5, 6
• Continuous IV insulin infusion is required 3

For non-ICU admission:

• Use scheduled subcutaneous basal-bolus insulin regimen rather than sliding scale alone 3, 7
• Basal insulin (long-acting) plus prandial (rapid-acting) and correction doses is preferred for patients with good oral intake 3
• Basal plus correction insulin only for patients with poor or no oral intake 3

Insulin Regimen Specifics

For IV insulin (critical patients):

• Continuous infusion is the most effective method for achieving glycemic targets 3
• Use validated protocols that allow predefined adjustments based on glycemic fluctuations 3
• Starting threshold should be no higher than 180 mg/dL 3, 4

For subcutaneous insulin (non-critical patients):

• Long-acting basal insulin analogs (glargine, detemir) are preferred for basal component 7
• Rapid-acting insulin analogs (aspart, lispro, glulisine) are recommended for bolus and correction doses 7
• Sliding scale insulin alone is strongly discouraged as sole treatment 3

Common Pitfalls to Avoid

• Never delay insulin therapy in patients with significant hyperglycemia and ketosis 1
• Do not stop insulin prematurely when glucose normalizes but ketosis persists 1
• Avoid overly aggressive correction - target 140-180 mg/dL, not normoglycemia, to prevent hypoglycemia 3
• Do not use sliding scale insulin as monotherapy - this approach is ineffective and strongly discouraged 3, 7
• Avoid tight glycemic control (<110 mg/dL) as this increases mortality risk 10-15 fold compared to moderate targets 3

Monitoring Requirements

• Bedside glucose monitoring before meals for eating patients 3
• Every 4-6 hours for patients not eating 3
• Every 30 minutes to 2 hours during IV insulin infusion 3
• Continue monitoring for ketones if initially present until resolution 1

Transition Planning

• Consult specialized diabetes or glucose management team when possible 3
• Measure hemoglobin A1c at admission to assess prior glycemic control and guide discharge planning 4
• Transition from IV to subcutaneous insulin requires overlap to prevent rebound hyperglycemia 3
• Resume or initiate long-term diabetes management with multiple-dose insulin regimen or oral agents as appropriate 1