What is the management approach for a patient with hyperglycemia, glycosuria, symptoms suggestive of a cerebrovascular accident, and signs of impaired renal function, such as proteinuria?

Management of Hyperglycemic Crisis with Suspected Stroke and Renal Involvement

This patient requires immediate emergency department evaluation for hyperosmolar hyperglycemic state (HHS) with concurrent stroke and acute kidney injury—begin aggressive IV fluid resuscitation with 0.9% NaCl at 15-20 ml/kg/hour and continuous IV insulin infusion at 0.1 units/kg/hour after confirming potassium >3.3 mEq/L. 1

Immediate Assessment and Stabilization

Critical Initial Evaluation

• Calculate effective osmolality immediately using the formula: 2[Na+ (mEq/L)] + glucose (mg/dL)/18 to confirm HHS (typically >320 mOsm/kg) 1
• Obtain arterial blood gas, complete blood count, comprehensive metabolic panel, urinalysis for ketones, and ECG to differentiate HHS from diabetic ketoacidosis and assess for myocardial infarction as a precipitating factor 1, 2
• Assess neurological status carefully as the CVA pain and altered mental status could represent either stroke or severe hyperglycemic encephalopathy 1
• Identify precipitating factors including stroke, infection, medication non-compliance, or myocardial infarction 1, 2

Emergency Fluid Resuscitation

• Start 0.9% NaCl at 15-20 ml/kg/hour in the first hour (approximately 1-1.5 liters for average adult) 1
• Replace estimated fluid deficit over 24 hours, ensuring osmolality decreases no more than 3 mOsm/kg/hour to prevent cerebral edema 1
• Monitor for cerebral edema if glucose falls too rapidly, particularly given the concurrent neurological symptoms 1

Insulin Therapy Protocol

Initiation and Titration

• Exclude hypokalemia (K+ <3.3 mEq/L) before starting insulin as insulin will drive potassium intracellularly and worsen hypokalemia 1
• Begin continuous IV regular insulin infusion at 0.1 units/kg/hour after potassium is confirmed adequate 1, 3
• Double the insulin dose every hour if blood glucose does not decrease by at least 50 mg/dL in the first hour until achieving a decline of 50-75 mg/dL/hour 1
• Target blood glucose of 180-270 mg/dL within 24 hours, not normoglycemia, to avoid osmotic complications 1

Monitoring Requirements

• Check blood glucose hourly during acute phase 1
• Monitor electrolytes, renal function, and neurological status every 2-4 hours 1, 2
• Maintain blood glucose between 140-180 mg/dL once stabilized in the critical care setting 1, 2

Renal Considerations

Proteinuria Management

• The frothy urine with 1000 mg/dL glycosuria indicates severe hyperglycemia-induced osmotic diuresis and possible diabetic nephropathy 1
• Avoid metformin and SGLT2 inhibitors given acute kidney injury risk from severe dehydration and potential renal impairment 2
• Adjust insulin dosing for renal function as decreased renal clearance increases hypoglycemia risk, particularly in elderly patients 2

Transition to Subcutaneous Insulin

Conversion Protocol

• Transition from IV to subcutaneous insulin only when blood glucose <300 mg/dL, patient is stable, and able to eat 1
• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrent ketoacidosis 2
• Start basal-bolus regimen at 0.3-0.5 units/kg/day, split 50/50 between basal and bolus insulin 1
• Use 60-80% of total daily IV insulin dose when calculating initial subcutaneous regimen 1

Critical Pitfalls to Avoid

Hypoglycemia Prevention

• Elderly patients are at substantially higher risk for hypoglycemia-related mortality (twofold increased mortality in hospitalized patients ≥70 years) 2
• Never use sliding-scale insulin alone without basal insulin as this approach is ineffective and increases glycemic variability 4, 5
• Adjust insulin doses for decreased oral intake, renal failure, and concurrent medications 2, 3

Osmotic Complications

• Avoid rapid correction of hyperglycemia as this can precipitate cerebral edema, particularly concerning given the CVA symptoms 1
• Do not target glucose <140 mg/dL in the acute phase as this increases hypoglycemia risk without improving outcomes 2

Stroke-Specific Considerations

• Treat any correctable underlying cause of hyperglycemic crisis, including stroke as recommended for DKA/HHS management 2
• The CVA pain requires urgent neuroimaging to differentiate acute stroke from hyperglycemic encephalopathy 2
• Maintain glucose 140-180 mg/dL in acute stroke patients as both hypoglycemia and severe hyperglycemia worsen neurological outcomes 2

Discharge Planning

• Schedule endocrinology or primary care follow-up within 1-2 weeks 1
• Educate that persistent glucose >300 mg/dL requires immediate medical attention 1
• Reconcile all diabetes medications and ensure prescriptions are filled before discharge 2
• Provide sick-day management education to prevent recurrent hyperglycemic crisis 2