What is the treatment for severe hyperglycemia with a blood glucose level of 568?

Treatment of Severe Hyperglycemia (Blood Glucose 568 mg/dL)

Immediately evaluate this patient for hyperosmolar hyperglycemic state (HHS) and initiate aggressive fluid resuscitation followed by insulin therapy, as blood glucose >600 mg/dL requires urgent assessment and treatment to prevent life-threatening complications. 1

Immediate Assessment (First 30-60 Minutes)

Rule out HHS or diabetic ketoacidosis (DKA) by obtaining:

• Arterial blood gas, complete blood count, comprehensive metabolic panel, blood glucose, urea, creatinine 1
• Serum or urine ketones to differentiate between HHS (minimal ketones) and DKA (significant ketonemia) 1, 2
• Calculate effective osmolality: 2[Na+ (mEq/L)] + glucose (mg/dL)/18 1, 3
• Assess mental status, degree of dehydration, vital signs, and respiratory status 1
• Identify precipitating factors: infection, medication non-compliance, myocardial infarction, stroke 1, 3

HHS is diagnosed when: effective serum osmolality ≥320 mOsm/kg, arterial pH >7.3, bicarbonate >15 mEq/L, minimal ketonuria/ketonemia, and altered mental status or severe dehydration 3, 4

Fluid Resuscitation (Priority #1)

Start with 0.9% normal saline at 15-20 mL/kg/hour in the first hour to restore circulatory volume and tissue perfusion 1, 3, 4. This typically means 1-1.5 liters in the first hour for most adults.

• Total body water deficit in HHS is approximately 100-200 mL/kg (typically 9 liters) 3
• Replace estimated fluid deficit over 24 hours, ensuring osmolality decreases no more than 3 mOsm/kg/hour to prevent cerebral edema 1, 3, 4
• Monitor fluid input/output and hemodynamic parameters every 2-4 hours 3

Insulin Therapy (After Excluding Hypokalemia)

Never start insulin before confirming serum potassium >3.3 mEq/L, as insulin drives potassium intracellularly and can precipitate life-threatening hypokalemia 1, 3

Once hypokalemia is excluded:

• Administer IV bolus of regular insulin 0.1-0.15 units/kg body weight 2, 3
• Follow with continuous IV insulin infusion at 0.1 units/kg/hour 1, 2, 3
• If blood glucose does not decrease by at least 50 mg/dL in the first hour, double the insulin dose every hour until achieving a decline of 50-75 mg/dL/hour 1, 3

Target blood glucose of 250-300 mg/dL in the first 24 hours (not normoglycemia) 3, 4. When blood glucose reaches 250-300 mg/dL, add 5% dextrose to IV fluids while continuing insulin infusion at a reduced rate 3

Electrolyte Management

Potassium replacement is critical:

• Once renal function is confirmed and serum potassium is known, add 20-40 mEq/L potassium to the infusion 3
• Total body potassium deficit is typically 4-6 mEq/kg 3

Phosphate replacement (20-30 mEq/L potassium phosphate) may be considered if serum phosphate <1.0 mg/dL or in patients with cardiac dysfunction, anemia, or respiratory depression 3

Monitoring Protocol

Blood glucose every 1 hour during acute phase 1, 2

Serum electrolytes, glucose, BUN, creatinine, and osmolality every 2-4 hours 3

Watch for cerebral edema if glucose falls too rapidly: lethargy, behavioral changes, seizures, incontinence, pupillary changes, bradycardia, respiratory arrest 1, 3

Transition to Subcutaneous Insulin

When patient is stable with blood glucose <300 mg/dL and able to eat:

• Administer basal subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1, 3
• Use basal-bolus regimen: 0.3-0.5 units/kg total daily dose, split 50/50 between basal and bolus insulin 1
• Initial subcutaneous dose should be 60-80% of total daily IV insulin dose 1

Critical Pitfalls to Avoid

Do not correct glucose or osmolality too rapidly - increases risk of cerebral edema, particularly in younger patients 1, 3

Do not use bicarbonate therapy - it does not improve outcomes in HHS 3

Do not stop insulin when glucose normalizes if mental status has not improved - continue until hyperosmolarity resolves 3

Do not use sliding scale insulin alone in critically ill patients - continuous IV insulin infusion is the standard of care 3

Target Glucose Ranges

For critically ill patients once stabilized: maintain blood glucose 140-180 mg/dL 1, 5. Avoid targets <140 mg/dL as harms increase with lower targets 5. The mortality associated with hypoglycemia is as high as that associated with hyperglycemia 6.