What is the protocol for managing hyperglycemia (high blood sugar)?

Hyperglycemia Management Protocol

For hospitalized patients with hyperglycemia, initiate insulin therapy when blood glucose exceeds 180 mg/dL, targeting a range of 140-180 mg/dL, using continuous intravenous insulin infusion in critically ill patients and scheduled basal-bolus subcutaneous insulin regimens in non-critically ill patients. 1, 2

Critical Care Setting (ICU Patients)

Glycemic Targets and Initiation

• Trigger insulin therapy when glucose >180 mg/dL and maintain levels between 140-180 mg/dL to reduce mortality and morbidity while avoiding hypoglycemia 1
• More stringent targets of 110-140 mg/dL may be considered for cardiac surgery patients and those with acute ischemic cardiac or neurological events, but only if achievable without significant hypoglycemia 1

Insulin Administration Protocol

• Use continuous intravenous insulin infusion as the treatment of choice due to its short half-life (<15 minutes) allowing rapid dose adjustments 1
• Administer regular insulin as 0.15 units/kg IV bolus, followed by continuous infusion at 0.1 units/kg/hour (5-7 units/hour in adults) 1
• If glucose does not decrease by 50 mg/dL in the first hour, double the insulin infusion rate hourly until achieving a steady decline of 50-75 mg/dL per hour 1
• When glucose reaches 250 mg/dL in DKA or 300 mg/dL in HHS, decrease infusion to 0.05-0.1 units/kg/hour and add 5-10% dextrose to IV fluids 1

Monitoring Requirements

• Monitor blood glucose every 30 minutes to 2 hours during IV insulin therapy to prevent both hypoglycemia and hyperglycemia 1
• Use validated written or computerized protocols that allow predefined adjustments based on glycemic fluctuations 1
• Avoid subcutaneous insulin in critically ill patients, particularly during hypotension or shock 1

Non-Critical Care Setting (General Medical/Surgical Floors)

Glycemic Targets

• Maintain preprandial glucose 140-180 mg/dL and random glucose <180 mg/dL for most non-critically ill patients 1, 2
• Initiate treatment when blood glucose persistently exceeds 140 mg/dL 1

Insulin Regimen Selection

For patients with good oral intake:

• Implement basal-bolus insulin regimen with basal, prandial, and correction components 1, 2, 3
• Start with total daily dose (TDD) of 0.3-0.5 units/kg 1, 2
• Distribute as 50% basal insulin (glargine or detemir) once daily and 50% as rapid-acting prandial insulin (lispro, aspart, or glulisine) divided before three meals 1, 2, 3
• Add correction doses with rapid-acting insulin for persistent hyperglycemia 2

For patients with poor or no oral intake:

• Use basal insulin alone or basal plus correction insulin regimen 1, 3
• Administer basal insulin (glargine) at 0.2-0.25 units/kg once daily 2
• Monitor glucose every 4-6 hours and provide correction insulin as needed 1, 3

Critical Pitfall to Avoid

• Never use sliding scale insulin (SSI) alone without basal insulin - this approach is strongly discouraged as it results in poor glycemic control, increased glucose variability, and higher risk of hospital complications 1, 3

Severe Hyperglycemia and Hyperglycemic Crises

Initial Assessment for DKA/HHS

• Evaluate for mental status changes, severe dehydration, fruity breath odor, abdominal pain, nausea/vomiting 2, 4
• Obtain immediate labs: complete metabolic panel, serum ketones, arterial blood gas (if DKA suspected), urinalysis 2, 4
• DKA diagnostic criteria: glucose >250 mg/dL, pH <7.3, bicarbonate <15 mEq/L, positive ketones 1
• HHS diagnostic criteria: glucose >600 mg/dL, pH >7.3, bicarbonate >15 mEq/L, effective serum osmolality >320 mOsm/kg 1

Fluid Resuscitation

• Initiate with 0.9% NaCl at 15-20 mL/kg/hour (1-1.5 L) in the first hour for adults to restore intravascular volume 1
• After initial expansion, use 0.45% NaCl at 4-14 mL/kg/hour if corrected sodium is normal or elevated; use 0.9% NaCl if corrected sodium is low 1
• Ensure osmolality decrease does not exceed 3 mOsm/kg/hour to prevent cerebral edema 1

Pediatric considerations (<20 years):

• Use 0.9% NaCl at 10-20 mL/kg/hour in first hour, not exceeding 50 mL/kg over first 4 hours 1
• Calculate continued fluid therapy to replace deficit evenly over 48 hours 1

Potassium Replacement

• Do not start insulin if potassium <3.3 mEq/L - replete potassium first to prevent life-threatening hypokalemia 1
• Once renal function assured and K+ >3.3 mEq/L, add 20-40 mEq/L potassium (2/3 KCl and 1/3 KPO4) to IV fluids 1

Transition from IV to Subcutaneous Insulin

Timing and Method

• Transition when patient is stable with glucose consistently <200 mg/dL and able to eat 2
• Administer basal subcutaneous insulin 2-4 hours BEFORE discontinuing IV insulin to prevent rebound hyperglycemia 2, 3, 4
• Calculate TDD based on last 6-8 hours of IV insulin requirements, then implement basal-bolus regimen 2

Monitoring and Hypoglycemia Prevention

Blood Glucose Monitoring

• For eating patients: check glucose before each meal and at bedtime 1, 2
• For NPO patients: check glucose every 4-6 hours 1, 3
• Use arterial or venous samples rather than finger-stick capillary testing for greater accuracy 1

Hypoglycemia Management

• Recognize that hypoglycemia risk increases with intensive insulin therapy 5
• Early warning symptoms include sweating, tremor, palpitations, hunger, confusion, and dizziness 5
• Treat mild-moderate hypoglycemia with oral sugar-containing foods; severe hypoglycemia requires IV dextrose or glucagon injection 5
• Have hypoglycemia treatment protocols readily available and monitor particularly during overnight hours 3

Quality Improvement Measures

• Consult specialized diabetes or glucose management teams when available 1
• Analyze hypoglycemia rates and track percentage of glucose values <150 and <180 mg/dL 1
• Use validated insulin titration protocols with standardized approaches to infusion preparation 1
• Document all insulin administration and subsequent glucose readings 3