Hyperglycemia Management in Sick Diabetic Patients

Initial Assessment and Monitoring

The American Diabetes Association recommends checking blood glucose levels immediately and confirming hyperglycemia (>140 mg/dL or >7.8 mmol/L) in sick diabetic patients 2, 3
For patients who are eating, point-of-care glucose monitoring should be performed before meals, while those not eating should be monitored every 4-6 hours 2, 4
More frequent monitoring (every 30 minutes to 2 hours) is required when using intravenous insulin 2
Assess for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) through laboratory tests including electrolytes, anion gap, and ketones 5
Identify and address any precipitating factors such as infection, myocardial infarction, or stroke 6

The American College of Cardiology recommends initiating intravenous insulin therapy when glucose is ≥180 mg/dL (10.0 mmol/L), with a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) for most patients 1
More stringent goals (110-140 mg/dL) may be appropriate for selected patients (e.g., cardiac surgery patients) if achievable without significant hypoglycemia 1, 6
Provide aggressive fluid resuscitation if dehydrated, and monitor electrolytes, particularly potassium, as hypokalaemia is common during treatment 5, 6

For diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), provide immediate fluid resuscitation to restore circulatory volume and tissue perfusion, and administer continuous IV insulin for moderate to severe DKA 5, 6
Monitor for and correct electrolyte imbalances, particularly potassium, and consider frequent subcutaneous insulin injections for mild to moderate DKA 6
When transitioning from IV to subcutaneous insulin, administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 5

Begin discharge planning at admission and update as patient needs change, ensuring appropriate follow-up appointments are scheduled before discharge 7, 8
Provide education on medication changes, blood glucose monitoring, and when to call healthcare providers 8

Avoid hypoglycemia, as intensive glycemic control with targets <110 mg/dL has been associated with increased mortality compared to more moderate targets (140-180 mg/dL) 2, 3
Consider patient-specific factors, such as higher glucose targets (up to 250 mg/dL) for terminally ill patients with short life expectancy 2
Hold metformin on the day of surgery and discontinue SGLT2 inhibitors 3-4 days before surgery 5
If a patient uses personal continuous glucose monitoring (CGM), consider continuing during hospitalization with confirmatory point-of-care testing 1