Management of Severe Hyperglycemia

Initial Assessment

The American Diabetes Association recommends evaluating for signs of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) by checking serum ketones, arterial pH, bicarbonate, osmolality, and mental status 1
Assess for dehydration, which is typically more severe in HHS (9 liters or 100-200 ml/kg total body water deficit) compared to DKA 1
Identify potential precipitating factors including infection, missed insulin doses, medications (corticosteroids, diuretics, beta-blockers), or intercurrent illness 2, 3
Monitor for altered mental status, which may indicate cerebral edema, a rare but potentially fatal complication 4

The American College of Physicians recommends beginning aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1
Target correction of estimated fluid deficits within the first 24 hours, with induced change in serum osmolality not exceeding 3 mOsm/kg/h 1

Administer an intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/h, as recommended by the American Association of Clinical Endocrinologists 1
If plasma glucose does not fall by 50 mg/dL from initial value in the first hour, double the insulin infusion rate every hour until a steady glucose decline between 50-75 mg/h is achieved 1

Monitor and replace potassium, as total body deficits in hyperglycemic crises typically include 4-6 mEq/kg of potassium, according to the American Heart Association 1
Once renal function is assured and serum potassium is known, add 20-40 mEq/L potassium to the infusion 1

Watch for hypoglycemia due to overzealous insulin treatment, as warned by the American Diabetes Association 4
Monitor for hypokalemia due to insulin administration and treatment of acidosis, as cautioned by the American College of Cardiology 4
Be alert for signs of cerebral edema, including lethargy, behavioral changes, seizures, incontinence, pupillary changes, bradycardia, and respiratory arrest, as advised by the American Academy of Neurology 1

Provide education on sick-day management, including when to contact healthcare providers, blood glucose goals, supplemental insulin use during illness, and maintaining hydration, as recommended by the American Diabetes Association 4
Emphasize the importance of never discontinuing insulin during illness, as stressed by the American Association of Clinical Endocrinologists 4