What is the treatment for a diabetic adult patient presenting with severe hyperglycemia (blood glucose level of 789 mg/dL)?

Treatment of Severe Hyperglycemia (Blood Glucose 789 mg/dL)

A blood glucose of 789 mg/dL requires immediate assessment for life-threatening hyperglycemic emergencies (diabetic ketoacidosis or hyperosmolar hyperglycemic state), followed by aggressive fluid resuscitation and insulin therapy under close medical supervision. 1

Immediate Assessment (First 30 Minutes)

Immediately evaluate for hyperglycemic crisis by checking: 1

• Mental status (altered consciousness suggests DKA or HHS)
• Hydration status (assess for severe dehydration)
• Presence of nausea/vomiting (suggests DKA)
• Arterial or venous pH (pH <7.3 indicates DKA)
• Serum or urine ketones (elevated ketones confirm DKA)
• Serum osmolality (calculate: 2[Na+ (mEq/L)] + glucose (mg/dL)/18) 1
• Electrolytes, especially potassium (critical before insulin administration)

If any of the following are present, this is a hyperglycemic emergency requiring immediate hospitalization: 2

• Altered mental status or confusion
• Vomiting or inability to maintain oral intake
• Ketones present in blood or urine
• pH <7.3 or bicarbonate <15 mEq/L
• Serum osmolality >320 mOsm/kg

Emergency Management (DKA or HHS Confirmed)

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. 1, 2 This typically requires an average of 9 liters over 48 hours in adults. 3

• Continue aggressive hydration to correct estimated fluid deficits over 24 hours 2
• Critical safety parameter: Change in serum osmolality must not exceed 3-8 mOsm/kg/hour to prevent cerebral edema 2, 1

Insulin Therapy (SECOND Priority)

Do NOT start insulin if potassium is <3.3 mEq/L - correct hypokalemia first to prevent life-threatening cardiac arrhythmias. 1, 4

Once potassium is ≥3.3 mEq/L: 1, 2

• IV bolus: 0.1 units/kg of regular insulin
• Continuous infusion: 0.1 units/kg/hour
• When glucose reaches 250-300 mg/dL, add 5% dextrose to IV fluids and reduce insulin infusion rate 1, 2
• Do not stop insulin infusion until ketoacidosis resolves (anion gap normalizes, pH >7.3) 2

Electrolyte Management

Potassium replacement is critical - hypokalaemia occurs in approximately 50% of patients during treatment and severe hypokalaemia (<2.5 mEq/L) is associated with increased mortality. 2

• Monitor potassium every 2-4 hours 1, 2
• Begin potassium replacement when serum level falls below 5.5 mEq/L (assuming adequate urine output) 1, 2

Transition to Subcutaneous Insulin

Administer basal subcutaneous insulin 2-4 hours BEFORE stopping IV insulin to prevent rebound hyperglycemia and recurrent ketoacidosis. 2 This is a common pitfall - premature termination of IV insulin without adequate subcutaneous coverage leads to treatment failure. 5

Non-Emergency Severe Hyperglycemia Management

If the patient is alert, able to take oral fluids, has no ketones, and normal pH: 1

Identify and Address Precipitating Cause

• Infection (most common cause - check for urinary tract infection, pneumonia, skin infections) 1, 3
• Missed or inadequate insulin doses 1
• New medications (corticosteroids, thiazide diuretics, beta-blockers) 6, 3
• Acute illness, myocardial infarction, or stroke 2, 1

Immediate Adjustments

• Increase blood glucose monitoring to every 2-4 hours 1
• Ensure adequate oral fluid intake (2-3 liters/day) to prevent dehydration 2
• Temporarily increase insulin doses - patients may require 2-3 times their usual insulin during acute illness 4
• If patient is on oral agents only, temporary insulin therapy is likely needed 2

When to Hospitalize

Persistent blood glucose >300 mg/dL despite intervention requires immediate medical attention and likely hospitalization. 1 Additional hospitalization criteria include: 2

• Inability to maintain adequate oral intake
• Progressive deterioration despite outpatient management
• Presence of significant comorbidities (heart failure, renal insufficiency)
• Lack of adequate home support or monitoring capability

Critical Monitoring Parameters

During treatment, monitor: 2, 1

• Blood glucose: Every 2-4 hours minimum
• Electrolytes (Na, K, Cl, HCO3): Every 2-4 hours
• Serum osmolality: Every 4-6 hours until stable
• Venous pH: Every 2-4 hours if DKA present
• Mental status: Continuously
• Urine output: Hourly

Common Pitfalls to Avoid

• Never discontinue basal insulin, even if patient is not eating - this can precipitate DKA in insulin-dependent patients 2, 4
• Avoid overly rapid correction of hyperglycemia (target glucose reduction of 50-75 mg/dL/hour) to prevent cerebral edema 2
• Do not use bicarbonate therapy - it does not improve outcomes and is generally not recommended 2
• Ensure adequate follow-up within 1-2 weeks with endocrinology or primary care to prevent recurrence 1

Patient Education Before Discharge

Teach patients to: 1

• Recognize hyperglycemic symptoms (excessive thirst, frequent urination, blurred vision, fatigue)
• Never discontinue insulin during illness - this is a critical survival rule 2, 1
• Increase monitoring frequency during illness
• Maintain adequate fluid intake during sick days
• Contact healthcare provider if glucose remains >300 mg/dL despite intervention 1