What is the treatment for an adult diabetic patient with severe hyperglycemia (high blood sugar)?

Management of Severe Hyperglycemia (Blood Glucose 484 mg/dL)

A blood glucose of 484 mg/dL requires immediate assessment for life-threatening hyperglycemic emergencies (diabetic ketoacidosis or hyperosmolar hyperglycemic state), followed by aggressive insulin therapy with either intravenous insulin infusion if critically ill or subcutaneous basal-bolus insulin regimen if stable. 1, 2

Immediate Assessment (First Priority)

Check immediately for hyperglycemic crisis by assessing the following: 2

• Mental status changes (confusion, drowsiness, altered consciousness)
• Signs of dehydration (dry mucous membranes, poor skin turgor)
• Presence of nausea, vomiting, or abdominal pain
• Fruity breath odor (acetone smell indicating ketosis)
• Rapid, deep breathing (Kussmaul respirations)

Obtain urgent laboratory tests: 1, 2

• Serum or urine ketones
• Complete metabolic panel (electrolytes, renal function)
• Arterial blood gas if ketoacidosis suspected
• Calculate effective osmolality: 2[Na+ (mEq/L)] + glucose (mg/dL)/18 2

Critical Decision Point

If ANY of the following are present, this is a medical emergency requiring hospitalization: 3, 2

• Ketones present with vomiting or altered mental status (indicates diabetic ketoacidosis)
• Severe dehydration
• Altered level of consciousness
• Blood glucose ≥600 mg/dL (consider hyperosmolar hyperglycemic state)

Management for Hyperglycemic Crisis (If Present)

Initiate immediate fluid resuscitation with 0.9% sodium chloride at 15-20 mL/kg/hour during the first hour to restore circulatory volume. 2

Start continuous intravenous insulin infusion after excluding severe hypokalemia (K+ <3.3 mEq/L): 1, 2

• IV bolus of 0.1 units/kg
• Followed by continuous infusion at 0.1 units/kg/hour
• Target glucose range of 140-180 mg/dL 1

Monitor blood glucose every 30 minutes to 2 hours during IV insulin therapy to prevent hypoglycemia. 1

Management for Stable Severe Hyperglycemia (No Crisis)

For Blood Glucose 484 mg/dL Without Ketoacidosis

Initiate subcutaneous basal-bolus insulin regimen immediately as this level of hyperglycemia (>300 mg/dL) requires complex insulin therapy, not oral agents alone. 3, 1

Calculate total daily insulin dose at 0.3-0.5 units/kg body weight: 1

• Distribute as 50% basal insulin (long-acting)
• Distribute as 50% prandial insulin (rapid-acting, divided before meals)

Specific insulin regimen: 1

• Basal insulin: Start glargine or detemir at 0.2-0.25 units/kg once daily
• Prandial insulin: Add rapid-acting insulin (lispro, aspart, or glulisine) before meals at 0.1-0.15 units/kg divided into three doses
• Correction doses: Provide additional rapid-acting insulin for persistent hyperglycemia using a correction factor

Critical Pitfall to Avoid

Do NOT use sliding scale insulin alone without basal insulin - this approach is ineffective and strongly discouraged by guidelines. 1, 4

Transition from IV to Subcutaneous Insulin (If Hospitalized)

Administer basal insulin 2-4 hours BEFORE discontinuing IV insulin to prevent rebound hyperglycemia. 1

Transition only when: 1

• Patient is stable
• Glucose levels consistently below 200 mg/dL
• Patient able to eat

Monitoring Requirements

Check blood glucose: 1, 2

• Before each meal and at bedtime (minimum 4 times daily)
• Every 4-6 hours during acute illness 2
• More frequently if adjusting insulin doses

Adjust insulin doses daily based on blood glucose patterns until stable control achieved. 1

Identify and Address Underlying Cause

Common causes of severe hyperglycemia requiring investigation: 2

• Missed or inadequate insulin doses
• New diagnosis of diabetes
• Intercurrent illness or infection
• Corticosteroid use
• Medication non-compliance

Ensure adequate fluid and caloric intake to prevent dehydration and electrolyte imbalances. 3, 2

When to Seek Immediate Medical Attention

Call emergency services or go to emergency department if: 3, 2

• Blood glucose remains >300 mg/dL over 2 consecutive days despite treatment
• Any symptoms of ketoacidosis develop (vomiting, abdominal pain, fruity breath, confusion)
• Unable to keep fluids down
• Persistent symptoms of severe hyperglycemia (excessive thirst, frequent urination, weakness)

Long-Term Management After Stabilization

Add metformin as first-line oral therapy (if renal function normal) once acute hyperglycemia controlled to prevent recurrence. 1, 2

Continue insulin therapy long-term if HbA1c >10% or if patient was severely insulin-deficient at presentation. 1

Schedule follow-up within 1-2 weeks to reassess glycemic control and adjust regimen. 1, 2

Provide diabetes self-management education including sick-day management and recognition of hyperglycemic symptoms. 1, 2

Important Safety Considerations

Monitor closely for hypoglycemia during insulin therapy - patients should always carry quick-acting sugar (hard candy or glucose tablets). 5

Never discontinue insulin during illness - insulin requirements may actually increase during stress or infection. 2, 5

Increase monitoring frequency to every 4-6 hours during any acute illness, infection, or stressful situation. 2, 5