From the Guidelines
For a patient with a blood glucose of 400 mg/dL and a normal anion gap, the immediate treatment should focus on insulin administration and fluid replacement, with a target glucose range of 140–180 mg/dL. According to the standards of medical care in diabetes-2020 1, insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL.
Key Considerations
- The patient's high blood glucose level indicates the need for prompt intervention to prevent complications such as hyperglycemic hyperosmolar state or worsening of diabetic ketoacidosis.
- The normal anion gap suggests that the patient does not have significant ketoacidosis, but rather hyperglycemia due to other causes such as poorly controlled type 2 diabetes.
- The treatment goal is to reduce blood glucose levels while avoiding hypoglycemia, which can be achieved by starting with an intravenous bolus of regular insulin at 0.1 units/kg followed by a continuous insulin infusion at 0.1 units/kg/hour, as suggested by clinical guidelines 1.
Treatment Approach
- Simultaneously, begin fluid resuscitation with normal saline at 15-20 mL/kg/hour for the first hour, then adjust to 250-500 mL/hour based on hydration status.
- Check blood glucose hourly and adjust the insulin infusion to achieve a glucose reduction of 50-75 mg/dL per hour.
- Once glucose reaches 250 mg/dL, add dextrose to IV fluids (D5 or D10) to prevent hypoglycemia while continuing insulin.
- Potassium replacement may be necessary if levels are low or normal, as insulin therapy will drive potassium intracellularly.
Long-term Management
- After stabilization, transition to subcutaneous insulin with a basal-bolus regimen, typically starting with 0.5-0.7 units/kg/day divided as 50% basal (glargine or detemir) and 50% prandial (lispro, aspart, or regular) insulin.
- Ensure the patient has follow-up care arranged and diabetes education before discharge, as recommended by the standards of medical care in diabetes-2020 1.
From the Research
Treatment for Glucose 400 with Normal Anion Gap
- The treatment for hyperglycemia with a glucose level of 400 mg/dL and a normal anion gap involves the administration of insulin and intravenous fluids 2.
- A study published in 2017 found that 10 units of subcutaneous insulin and 1 liter of intravenous fluid were associated with a glucose reduction of 33 mg/dL and 27 mg/dL, respectively 2.
- However, the administration of intravenous fluids was also associated with a significant increase in emergency department length of stay, whereas insulin administration was not 2.
Insulin Therapy
- Insulin therapy is a common treatment for hyperglycemia, and the choice of insulin regimen depends on various factors, including the severity of hyperglycemia and the patient's medical condition 3.
- A study published in 2007 recommended the use of continuous intravenous insulin infusions or intermittent subcutaneous basal-bolus plus correction injections for managing hyperglycemia in hospitalized patients 3.
- Another study published in 2020 found that intravenous insulin therapy was effective in reducing blood glucose levels in patients with hyperglycemic crisis and intercurrent illness, but the dosage and frequency of insulin administration varied widely among patients 4.
Management of Hyperglycemia
- The management of hyperglycemia in the emergency department is a complex issue, and optimal management strategies are still being developed 5.
- A review published in 2017 highlighted the importance of proper management of hyperglycemia in the emergency department, including the use of insulin and intravenous fluids, and emphasized the need for further research on the outcomes and cost-effectiveness of various management strategies 5.
- A practical guidance on the use of intravenous insulin infusion for managing inpatient hyperglycemia was published in 2021, which provided recommendations for adjusting infusion rates based on blood glucose levels and other factors 6.