What is the recommended blood glucose management in a code stroke scenario?

Blood Glucose Management in Code Stroke

In a code stroke scenario, initiate insulin therapy when blood glucose persistently exceeds 180 mg/dL, targeting a range of 140-180 mg/dL, while aggressively treating any hypoglycemia below 60 mg/dL immediately. 1, 2

Initial Assessment and Monitoring

• Check blood glucose immediately upon stroke presentation as part of the initial code stroke protocol 1, 2
• Monitor glucose every 1-2 hours initially in critically ill stroke patients, particularly those requiring insulin therapy 2, 3
• Use continuous glucose monitoring when available, as standard point-of-care testing may miss nocturnal hypoglycemic events that occur in approximately 49% of acute stroke patients 4

Treatment Thresholds and Targets

The consensus recommendation across major guidelines is to treat hyperglycemia at 180 mg/dL with a target range of 140-180 mg/dL. 1, 2, 5

When to Initiate Insulin:

• Start insulin therapy when glucose persistently exceeds 180 mg/dL 1, 2, 5
• For critically ill patients or those receiving thrombolytic therapy, use intravenous insulin infusion for the first 24-48 hours 3
• Typical starting rate is 0.5 units/hour of regular insulin, adjusted to maintain the 140-180 mg/dL target 2

Avoid Aggressive Glucose Lowering:

• Do not target normoglycemia or glucose levels below 140 mg/dL in the acute stroke setting 1, 6
• The GIST-UK trial, the only large randomized study testing aggressive glucose lowering in acute stroke, showed no outcome benefit and was stopped early 1
• Meta-analyses demonstrate increased severe hypoglycemia and mortality with tight glycemic control compared to moderate control 1, 2

Critical Pitfalls to Avoid

Hypoglycemia is More Dangerous Than Mild Hyperglycemia:

• Hypoglycemia (<60 mg/dL) causes permanent brain damage and worsens ischemic injury 1, 6
• Treat hypoglycemia immediately with glucose administration—this is readily reversible unlike hyperglycemia-related injury 6
• Hypoglycemic events occur most commonly during nighttime hours, even in patients with normal admission glucose 4

Don't Delay Treatment of Severe Hyperglycemia:

• Persistent hyperglycemia during the first 24 hours is associated with increased cerebral edema, hemorrhagic transformation, lower recanalization rates, and increased mortality 6, 7
• Admission hyperglycemia predicts symptomatic intracranial hemorrhage in patients receiving IV thrombolysis 1

Special Populations

Type 1 Diabetes or Critically Ill Patients:

• Use intravenous insulin infusion rather than subcutaneous protocols 2, 3
• Prime IV tubing with 20 mL waste volume using regular insulin at 1 unit/mL concentration 2
• Patients on stress-dose steroids require 2-3 times their usual insulin dose due to increased insulin resistance 2

Stable Patients Without Critical Illness:

• Subcutaneous insulin protocols are sufficient and can safely maintain glucose in the 140-180 mg/dL range without excessive resource utilization 1, 3
• Transition from IV to subcutaneous insulin after 24-48 hours, using basal long-acting insulin plus correction doses 3

Evidence-Based Rationale

The American Heart Association and American Diabetes Association both recommend the 140-180 mg/dL target range based on critical care literature showing this approach balances glycemic control against hypoglycemia risk 1, 2. While observational studies consistently show associations between hyperglycemia and worse stroke outcomes, interventional trials have not demonstrated that correcting hyperglycemia improves functional outcomes 1, 7. The primary goal is therefore harm reduction—preventing both the detrimental effects of severe hyperglycemia and the potentially catastrophic consequences of hypoglycemia in the acutely ischemic brain 1, 6.