What is the management of decreased sensorium (altered mental status) due to hyperglycemia?

Management of Decreased Sensorium in Hyperglycemia

When a patient presents with altered mental status and hyperglycemia, immediately assess for life-threatening hyperglycemic emergencies—diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS)—as these conditions require urgent medical intervention to prevent complications and death. 1

Immediate Assessment and Diagnostic Workup

Check blood glucose, serum electrolytes, ketones (blood or urine), arterial or venous pH, and serum osmolality urgently to differentiate between DKA and HHS. 2

Key Diagnostic Criteria:

• DKA: Presence of ketosis with metabolic acidosis (low serum bicarbonate/TCO2, elevated anion gap), typically with glucose >250 mg/dL but can be euglycemic 3, 4
• HHS: Plasma glucose ≥600 mg/dL, serum osmolality ≥320 mOsm/kg, minimal to no ketosis, and impaired mental status 5
• Critical finding: The severity of acidosis (low TCO2 and high anion gap) strongly correlates with the degree of altered consciousness in hyperglycemic patients, not the glucose level itself 4

Signs Requiring Immediate Medical Care:

• Altered mental status, confusion, drowsiness, or coma 1
• Ketosis with vomiting 1
• Signs of severe dehydration 2, 6
• Kussmaul respirations (deep, rapid breathing) 3

Emergency Treatment Protocol

Fluid Resuscitation (First Priority):

Begin immediate fluid resuscitation with 0.9% sodium chloride at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion. 2, 5

Insulin Therapy:

Administer intravenous insulin bolus of 0.1 units/kg body weight, followed by continuous infusion at 0.1 units/kg/hour. 2

• Monitor blood glucose every 2-4 hours 2
• Draw blood every 2-4 hours for electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 2

Electrolyte Management:

Carefully monitor and correct electrolyte imbalances, particularly potassium, as both DKA and HHS cause significant electrolyte disturbances. 2, 5

Transition to Subcutaneous Insulin

Transition from intravenous to subcutaneous insulin 2-4 hours before stopping intravenous insulin to prevent rebound hyperglycemia. 2

Target glucose levels for non-critically ill patients:

• Pre-meal glucose <140 mg/dL (7.8 mmol/L) 2
• Random glucose <180 mg/dL (10.0 mmol/L) 2

Critical Management Principles

Specialist Involvement:

A clinician with expertise in diabetes management should treat the hospitalized patient with hyperglycemic emergencies. 1

Ongoing Monitoring Requirements:

• More frequent blood glucose monitoring is necessary during any intercurrent illness 1
• Ketosis-prone patients require urine or blood ketone monitoring 1

Medication Adjustments:

Patients treated with noninsulin therapies or medical nutrition therapy alone may temporarily require insulin during acute hyperglycemic crises with altered mental status. 1

Special Populations and Pitfalls

High-Risk Groups Requiring Lower Threshold for Intervention:

• Pregnant patients: Can develop euglycemic DKA (glucose <200 mg/dL) with significant risk of feto-maternal harm 3
• Patients on SGLT2 inhibitors: Can develop euglycemic DKA with normal or near-normal glucose levels 3
• Children: Higher risk of cerebral edema during fluid resuscitation 3

Critical Pitfall to Avoid:

Never discontinue insulin during intercurrent illness, even if the patient is not eating, as this can precipitate DKA. 2, 3

Discharge Planning

Develop a structured discharge plan that addresses the underlying precipitating cause, ensures patient education on sick-day management, and establishes close follow-up. 2

• Ensure adequate fluid and caloric intake 1
• Educate on when to check ketones (glucose >200 mg/dL, illness symptoms, missed insulin doses) 3
• Emphasize that infection or dehydration more commonly necessitates hospitalization in patients with diabetes 1