How should I manage a patient with a blood glucose of 562 mg/dL?

Management of Blood Glucose 562 mg/dL

Immediately initiate insulin therapy for this patient with severe hyperglycemia, as insulin therapy should be started for persistent hyperglycemia at a threshold of 180 mg/dL, targeting a glucose range of 140-180 mg/dL for most hospitalized patients. 1, 2

Immediate Assessment and Risk Stratification

Before starting treatment, rapidly assess for life-threatening hyperglycemic emergencies:

• Evaluate for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) by checking mental status, hydration status, presence of vomiting, fruity breath odor (acetone), rapid breathing (Kussmaul respirations), and signs of severe dehydration 2, 3
• Obtain point-of-care blood glucose confirmation and send laboratory tests including basic metabolic panel, anion gap, venous pH, and urinalysis for ketones 2, 3
• Check A1C if not available from the previous 3 months to distinguish pre-existing diabetes (A1C ≥6.5%) from new-onset or hospital-related hyperglycemia 1, 2
• Determine if the patient is critically ill (requiring ICU-level care, on ventilator, hemodynamically unstable) versus non-critically ill, as this determines insulin delivery method 2

Insulin Therapy Initiation

For Critically Ill Patients

• Start continuous intravenous insulin infusion immediately using a validated protocol, typically beginning with 0.1 units/kg/hour 2, 1
• Target glucose range of 140-180 mg/dL for the majority of critically ill patients 1, 2
• Avoid targeting glucose <110 mg/dL, as the NICE-SUGAR trial demonstrated increased mortality (27.5% vs 25%) and 10- to 15-fold greater rates of hypoglycemia with intensive glycemic control (80-110 mg/dL) compared to moderate targets (140-180 mg/dL) 1, 2
• Monitor blood glucose every 1-2 hours initially until stable within target range, then transition to every 4-6 hours 2

For Non-Critically Ill Patients

• Use basal-bolus subcutaneous insulin regimen rather than continuous IV infusion 1
• Basal insulin (glargine or detemir) plus rapid-acting prandial insulin (aspart, lispro, or glulisine) with correction doses is the preferred treatment for non-critically ill hospitalized patients with good nutritional intake 1, 4
• Basal insulin alone or basal plus correction insulin is preferred for patients with poor oral intake or those taking nothing by mouth 1
• Target pre-meal glucose <140 mg/dL and random blood glucose <180 mg/dL for non-critically ill patients 1, 5
• Strongly avoid sliding-scale insulin as the sole regimen, as it is ineffective and excludes the critical basal insulin component 1, 4

Critical Monitoring and Safety

• Establish a hypoglycemia management protocol with clear treatment thresholds, as hypoglycemia is associated with increased inpatient mortality 2, 1
• Monitor for hypoglycemia (blood glucose <70 mg/dL) every 1-2 hours initially, then every 4-6 hours once stable 2
• If hypoglycemia occurs, immediately administer 15-20 grams of oral glucose for conscious patients, or 10-20 grams of IV 50% dextrose for patients with altered mental status 6
• Avoid overcorrection that causes iatrogenic hyperglycemia, as rapid glucose fluctuations increase complications 6

Special Considerations for DKA/HHS

If the patient meets criteria for DKA or HHS:

• Continuous insulin infusion is mandatory for moderate-to-severe DKA, though mild-to-moderate DKA may be treated with frequent subcutaneous insulin 1, 3
• Aggressive fluid resuscitation with isotonic saline is essential before or concurrent with insulin therapy 3
• Monitor potassium closely and replace aggressively, as hypokalaemia occurs in approximately 50% of patients during treatment and severe hypokalaemia (<2.5 mEq/L) is associated with increased mortality 1
• Do not delay insulin therapy, but ensure adequate fluid resuscitation and potassium repletion 3

Common Pitfalls to Avoid

• Never use sliding-scale insulin alone without basal insulin coverage, as this approach is ineffective and strongly discouraged 1, 4
• Do not target euglycemia (80-110 mg/dL) in hospitalized patients, as this increases mortality and severe hypoglycemia risk 1, 2
• Avoid using only correction doses without scheduled basal and prandial insulin in patients eating meals 1
• Do not continue home oral diabetes medications in most hospitalized patients with severe hyperglycemia, as insulin is the most appropriate agent 1, 4

Transition and Discharge Planning

• Once stable and close to discharge from ICU, transition from continuous insulin infusion to subcutaneous insulin when the patient has stable glucose for 4-6 hours consecutively, normal anion gap, hemodynamic stability, and a stable nutrition plan 1
• Provide clear diabetes management instructions at discharge and ensure diabetes type is clearly documented in the medical record 2
• Arrange appropriate outpatient follow-up within 1-2 weeks to adjust the diabetes regimen and prevent readmission 2