What should be done for a patient with a blood glucose level of 260 mg/dL?

Management of Blood Glucose 260 mg/dL

For a patient with blood glucose of 260 mg/dL, you should call the provider as soon as possible and initiate insulin therapy if this level persists within a 24-hour period, as this represents significant hyperglycemia requiring intervention. 1

Immediate Assessment and Notification

• Contact the provider promptly when glucose values exceed 250 mg/dL within a 24-hour period, as this triggers the alert threshold requiring medical intervention 1
• Check for symptoms of hyperglycemia including altered mental status, vomiting, or poor oral intake that would necessitate immediate provider notification 1
• Verify the reading is accurate by ensuring proper testing technique and considering a repeat measurement if clinically indicated 2

Clinical Context Matters

The appropriate response depends heavily on the clinical setting:

For Hospitalized Non-Critically Ill Patients

• Insulin therapy should be initiated for persistent hyperglycemia at this level, as the threshold for starting insulin is 180 mg/dL 1
• Target glucose range of 140-180 mg/dL for most hospitalized patients once insulin is started 1
• Premeal glucose targets should generally be <140 mg/dL for non-critically ill patients on insulin 1
• More stringent goals of 110-140 mg/dL may be appropriate for selected patients if achievable without significant hypoglycemia 1

For Critically Ill Patients (ICU Setting)

• Intravenous insulin infusion should be used when glucose exceeds 180 mg/dL 1
• Maintain glucose between 140-180 mg/dL once IV insulin is started, with greater benefit potentially realized at the lower end of this range 1
• Avoid targets below 110 mg/dL due to increased mortality risk demonstrated in the NICE-SUGAR trial 1

For Long-Term Care Facility Residents

• The 260 mg/dL reading triggers the "call as soon as possible" protocol, as it exceeds 250 mg/dL within a 24-hour period 1
• This is particularly important for older adults where preventing both hyperglycemic complications and hypoglycemia must be balanced 1

Treatment Approach

Insulin Initiation

• Basal insulin or basal-bolus regimen is preferred over sliding scale insulin alone, which is strongly discouraged 1
• For patients with poor oral intake or NPO status, use basal insulin or basal plus correction insulin 1
• For patients with good nutritional intake, use basal, prandial, and correction insulin components 1

Monitoring Requirements

• Check blood glucose frequently after initiating treatment, typically every 1-2 hours initially until stable 1
• Reassess the insulin regimen if glucose falls below 100 mg/dL to avoid hypoglycemia 1
• Modify the regimen when glucose drops below 70 mg/dL unless easily explained by missed meals 1

Special Considerations and Pitfalls

Avoid These Common Errors

• Do not use sliding scale insulin alone as the sole treatment strategy—this approach is ineffective and strongly discouraged 1
• Do not target overly tight control (<140 mg/dL) without careful monitoring, as this increases hypoglycemia risk 3
• Do not ignore this level thinking it will resolve spontaneously—persistent hyperglycemia above 250 mg/dL requires intervention 1

Identify Precipitating Factors

• Look for underlying infections, which are the most common precipitant of severe hyperglycemia 4
• Review medications that may cause hyperglycemia (steroids, certain antipsychotics, vasopressors) 4
• Assess for medication nonadherence in patients with known diabetes 4
• Consider undiagnosed diabetes if this is a new finding, particularly if A1C ≥6.5% 1

Risk of Progression

• A glucose of 260 mg/dL places the patient at risk for hyperosmolar hyperglycemic state (HHS), especially if accompanied by dehydration 5, 4
• Monitor for marked hyperglycemia (≥30 mmol/L or 540 mg/dL), elevated osmolality, and profound dehydration 5
• HHS requires aggressive fluid resuscitation averaging 9 L of 0.9% saline over 48 hours in adults 4

Stroke and Acute Illness Context

• If the patient has acute ischemic stroke, initiate rapid-acting insulin for glucose >140 mg/dL, as hyperglycemia worsens stroke outcomes 1
• In septic patients, aim to keep glucose >70 mg/dL but do not target upper limits <150 mg/dL due to increased mortality with tight control 1

Documentation and Follow-Up

• Document the glucose level, time of measurement, patient symptoms, and provider notification 1
• For patients without prior diabetes diagnosis who exhibit hyperglycemia, ensure appropriate follow-up testing and care is documented at discharge 1
• Consider checking A1C to determine if diabetes preceded hospitalization (A1C ≥6.5% suggests pre-existing diabetes) 1