From the Guidelines
The patient requires immediate management for hyperglycemic crisis with evidence of fluid overload, and I recommend administering 0.1 units/kg of regular insulin IV as a bolus, followed by an insulin drip at 0.1 units/kg/hour, with a target glucose range of 140-180 mg/dL, as suggested by the most recent guidelines 1. The patient's presentation, including significant hyperglycemia (glucose >500 mg/dL in urine, serum 198 mg/dL), acute kidney injury (creatinine 1.41 mg/dL, BUN 23 mg/dL), and inflammation (CRP 16.9 mg/L, WBC 11.8), necessitates careful management to prevent further complications. Key considerations in management include:
- Fluid management should be cautious given the pulmonary vascular congestion seen on chest X-ray and elevated BNP (364), suggesting heart failure, starting with a slower rate of isotonic fluids (NS or LR) at 250-500 mL over the first hour.
- Monitoring glucose hourly and adjusting the insulin drip to achieve a decrease of 50-75 mg/dL per hour, with the addition of dextrose to IV fluids once glucose reaches 250 mg/dL to prevent hypoglycemia.
- Investigating the underlying cause of this presentation, which could include infection or cardiac decompensation, while simultaneously treating the metabolic derangements, as supported by guidelines from 2 and 1. The most recent and highest quality study, 1, emphasizes the importance of achieving a target glucose range of 140-180 mg/dL for the majority of critically ill patients, which guides the recommendation for insulin therapy in this patient.
From the FDA Drug Label
The intravenous administration of Humulin R U-100 was tested in 21 patients with type 1 diabetes ... During the assessment phase patients received intravenous Humulin R at an initial dose of 0.5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL).
The patient's glucose level is 198 mg/dL. To manage this in the emergency department, the dose of insulin can be started at 0.5 U/h and adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL) 3.
- Key considerations:
- Initial dose: 0.5 U/h
- Target glucose range: 100 to 160 mg/dL
- Adjust dose as needed to maintain target range.
From the Research
Management of Hyperglycemia in the Emergency Department
The patient's blood glucose level is 198 mg/dL, and the urinalysis shows glucose >500. According to the studies, insulin therapy is the most appropriate method for controlling glycemia in hospitalized patients 4, 5, 6.
Insulin Dosage
The studies recommend different modalities of insulin therapy, including continuous intravenous insulin infusion and scheduled basal-bolus-correction insulin 5, 6. The initial dose of insulin can be calculated based on the patient's weight, with a starting dose of 0.3 unit per kg for augmentation therapy or 0.6 to 1.0 unit per kg for replacement therapy 7.
Target Blood Glucose Concentrations
The target blood glucose concentrations depend on whether patients are critically ill or not. For critically ill patients, blood glucose levels >180 mg/dL may increase the risk of hospital complications, and blood glucose levels <110 mg/dL have been associated with an increased risk of hypoglycemia 5. For non-critically ill patients, the ideal glucose goals remain undefined and must be individualized according to the characteristics of the patients 5.
Key Considerations
- Insulin is the most appropriate pharmacologic agent for effectively controlling glycemia in hospital 4, 5, 6.
- Continuous intravenous insulin infusion is the best method for achieving glycemic targets in critically ill patients 5.
- A basal-bolus insulin strategy resulted in better glycemic control than sliding scale insulin and lower risk of hypoglycemia than premixed insulin regimen 5.
- Prevention of hypoglycemia is equally as important to patient outcomes and is an equally necessary part of any effective glucose control program 6.
- Modern insulin analogs offer advantages over the older human insulins because their time-action profiles more closely correspond to physiological basal and prandial insulin requirements, and have a lower propensity for inducing hypoglycemia than human insulin formulations 6.
Recommended Insulin Regimens
- Continuous intravenous insulin infusion for critically ill patients 5, 6.
- Scheduled subcutaneous basal-bolus insulin regimens supplemented with correction doses as needed and adjusted daily with the guidance of frequent blood glucose monitoring for non-critically ill patients 6.
- Long-acting basal insulin analogs (glargine, detemir) are suitable and preferred for the basal component of therapy; rapid-acting insulin analogs (aspart, lispro, glulisine) are recommended for bolus and correction doses 6.