What is the best course of action for a confused patient with hyperglycemia (elevated blood glucose levels)?

Management of Confused Patient with Hyperglycemia

Immediately assess for life-threatening hyperglycemic emergencies (diabetic ketoacidosis or hyperosmolar hyperglycemic state) and initiate urgent medical intervention, as marked hyperglycemia with altered mental status requires immediate treatment to prevent complications and death. 1

Immediate Assessment (First 60 Minutes)

Check for hyperglycemic crisis indicators urgently:

• Measure blood glucose, serum electrolytes, ketones (blood or urine), arterial or venous pH, and serum osmolality 1, 2
• Calculate serum osmolality using: (2 × Na+) + glucose + urea; osmolality ≥320 mOsm/kg indicates hyperosmolar hyperglycemic state 3
• Assess hydration status, mental status changes (drowsiness, lethargy, confusion, coma), and signs of dehydration 4, 2
• Look for precipitating causes: infection (most common), missed insulin doses, concurrent illness, or medications (corticosteroids) 4, 2

Key diagnostic criteria to distinguish emergencies:

• DKA: Glucose typically >250 mg/dL, ketones >3.0 mmol/L, pH <7.3, bicarbonate <15 mmol/L 3
• HHS: Glucose ≥30 mmol/L (≥540 mg/dL), osmolality ≥320 mOsm/kg, ketones ≤3.0 mmol/L, pH >7.3, bicarbonate ≥15 mmol/L 3
• Mixed presentations occur in up to one-third of patients 5

Immediate Treatment Protocol

Fluid Resuscitation (Cornerstone of Therapy)

Begin aggressive intravenous fluid replacement immediately:

• Start 0.9% sodium chloride at 15-20 mL/kg/hour during the first hour to restore circulatory volume 1
• Average adult requirements: 9 liters over 48 hours (fluid losses typically 100-220 mL/kg) 2, 3
• Monitor urine output (target ≥0.5 mL/kg/hour) and adjust fluid rate accordingly 3
• Exercise caution in elderly patients due to risk of fluid overload 3

Insulin Therapy

Timing of insulin initiation depends on the type of crisis:

• For DKA or mixed presentations with significant ketosis: Start insulin immediately alongside fluids 1, 6
• For pure HHS without ketonaemia: Delay insulin until osmolality stops falling with fluid replacement alone 3

Insulin dosing regimen:

• Administer IV bolus of 0.1 units/kg body weight, followed by continuous infusion at 0.1 units/kg/hour 1, 2
• Alternative: Continuous infusion at 0.14 units/kg/hour without initial bolus 2
• Monitor blood glucose every 2-4 hours 1
• Continue IV insulin until blood glucose <300 mg/dL (for DKA, continue until ketonemia resolves) 1, 6

Electrolyte Replacement

Potassium management is critical:

• Begin potassium replacement once urine output is established 1
• Monitor serum potassium every 2-4 hours and replace according to levels 1, 3
• Hypokalemia is a common and dangerous complication requiring vigilant monitoring 6

Glucose Management During Treatment

Once blood glucose decreases:

• Start 5% or 10% glucose infusion when blood glucose falls below 14 mmol/L (252 mg/dL) 3
• Target blood glucose 10-15 mmol/L (180-270 mg/dL) in first 24 hours for HHS 3
• For non-critically ill patients after stabilization: target pre-meal glucose <140 mg/dL and random glucose <180 mg/dL 1

Ongoing Management and Monitoring

Monitor closely during treatment:

• Check blood glucose every 2-4 hours 1
• Draw blood every 2-4 hours for electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 1
• Aim for gradual decline in osmolality (3.0-8.0 mOsm/kg/hour) to minimize risk of cerebral edema 3

Transition from IV to subcutaneous insulin:

• Begin subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1
• Critical pitfall: Premature termination of IV insulin or insufficient subcutaneous insulin dosing before discontinuing IV insulin leads to treatment failure 6

Common Pitfalls to Avoid

Do not use sliding-scale insulin alone as monotherapy—this approach is ineffective and causes wide glucose fluctuations 4, 7

Never discontinue insulin in type 1 diabetes patients, even when infection resolves, as this precipitates DKA 7

Avoid overly rapid correction of osmolality (>8.0 mOsm/kg/hour), which increases risk of cerebral edema and osmotic demyelination 3

Do not delay treatment to obtain complete history in a confused patient—begin immediate assessment and intervention while gathering information 1

Resolution Criteria and Discharge Planning

HHS resolution indicators:

• Osmolality <300 mOsm/kg 3
• Hypovolemia corrected (urine output ≥0.5 mL/kg/hour) 3
• Cognitive status returned to baseline 3
• Blood glucose <270 mg/dL 3

Develop structured discharge plan:

• Address underlying precipitating cause (infection, medication non-adherence) 1, 7
• Provide diabetes self-management education focusing on sick-day management 7
• Establish close follow-up to prevent recurrence 1, 6
• Educate on never discontinuing insulin during intercurrent illness 7