Initial Treatment for Hyperglycemia in the Emergency Department

Initial Assessment and Fluid Resuscitation

The American Diabetes Association recommends restoring intravascular volume and tissue perfusion as the first priority, not lowering glucose, in patients presenting to the ED with severe hyperglycemia 1, 2
Obtain immediate labs, including arterial blood gases, complete blood count with differential, urinalysis, plasma glucose, blood urea nitrogen, electrolytes with calculated anion gap, creatinine, osmolality, and electrocardiogram, in patients with severe hyperglycemia 1, 2
Start isotonic saline (0.9% NaCl) at 15-20 ml/kg body weight per hour during the first hour in the absence of cardiac compromise, in patients with severe hyperglycemia 1, 2, 3

The American Diabetes Association recommends continuous intravenous insulin as the treatment of choice for moderate to severe hyperglycemia in the ED setting 1, 3, 5
Exclude hypokalemia (K+ must be >3.3 mEq/L) before starting insulin to prevent life-threatening cardiac arrhythmias in patients with DKA or severe hyperglycemia 1, 3, 6
Give an intravenous bolus of regular insulin at 0.15 units/kg body weight, followed by continuous IV infusion at 0.1 units/kg/h, in patients with DKA or severe hyperglycemia 1, 3, 6

If plasma glucose does not fall by at least 50 mg/dL in the first hour, double the insulin infusion rate every hour until achieving steady glucose decline of 50-75 mg/h, in patients with severe hyperglycemia 4, 6
Check blood glucose every 2-4 hours, along with electrolytes, BUN, creatinine, osmolality, and venous pH, in patients with severe hyperglycemia 4, 7

Add 20-40 mEq/L potassium to IV fluids, once renal function is confirmed and serum potassium is known, in patients with severe hyperglycemia 4, 2, 8
Continue monitoring potassium levels every 2-4 hours during treatment, in patients with severe hyperglycemia 4, 7

Never start insulin before excluding hypokalemia (K+ <3.3 mEq/L), as this can precipitate fatal cardiac arrhythmias, in patients with severe hyperglycemia 1, 3, 6
Avoid sliding-scale insulin alone in the inpatient setting, as it is strongly discouraged and ineffective, according to the American College of Physicians 9, 10

When transitioning from IV to subcutaneous insulin, administer basal insulin 2-4 hours before discontinuing the IV infusion, to prevent rebound hyperglycemia and recurrent ketoacidosis, in patients with severe hyperglycemia 5
Converting to basal insulin at 60-80% of the total daily IV insulin dose is effective, according to the American College of Physicians 9, 10