Management of Severe Hyperglycemia

Immediate Assessment and Diagnosis

The American Diabetes Association recommends checking arterial blood gases, complete blood count, urinalysis, plasma glucose, electrolytes, BUN, creatinine, and obtaining an ECG immediately for patients with glucose levels >400 mg/dL 1
DKA criteria include pH <7.3, bicarbonate <15 mEq/L, moderate ketonuria/ketonemia, according to the American Diabetes Association 1
HHS criteria include pH >7.3, bicarbonate >15 mEq/L, effective serum osmolality >320 mOsm/kg, as defined by the American Diabetes Association 1
Calculated corrected sodium should be determined by adding 1.6 mEq to measured sodium for each 100 mg/dL glucose above 100 mg/dL, as recommended by the American Diabetes Association 1

The American Diabetes Association recommends starting with 0.9% normal saline at 10-20 ml/kg/hour (approximately 1-1.5 liters in the first hour for adults) for fluid resuscitation 1
In severely dehydrated patients, the American Diabetes Association suggests repeating this bolus, but not exceeding 50 ml/kg over the first 4 hours 1
Fluid therapy should be continued at 1.5 times the 24-hour maintenance requirements (approximately 5 ml/kg/hour) to replace deficit evenly over 48 hours, according to the American Diabetes Association 1
The American Diabetes Association recommends switching to 0.45-0.9% NaCl based on corrected serum sodium levels, ensuring osmolality decrease does not exceed 3 mOsm/kg/H2O per hour 1

The American Diabetes Association recommends giving an initial IV bolus of regular insulin at 0.15 units/kg body weight for adults with severe hyperglycemia (>400 mg/dL) 1
Continuous infusion of regular insulin at 0.1 units/kg/hour (typically 5-7 units/hour in adults) is recommended by the American Diabetes Association and The Lancet Diabetes and Endocrinology 1, 3
The American Diabetes Association recommends targeting a glucose decline of 50-75 mg/dL per hour 1
If glucose does not fall by 50 mg/dL in the first hour, the American Diabetes Association suggests verifying adequate hydration, then doubling the insulin infusion rate hourly until achieving steady decline 1

The Lancet Diabetes and Endocrinology reports that hypokalemia occurs in approximately 50% of patients during treatment and severe hypokalemia (<2.5 mEq/L) increases mortality 3
The American Diabetes Association recommends adding 20-40 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO4) once renal function is confirmed and serum potassium is known 1
The American Diabetes Association advises not starting insulin if potassium is <3.3 mEq/L until potassium is repleted 1
The Lancet Diabetes and Endocrinology recommends monitoring potassium levels closely throughout treatment 3

The Lancet Diabetes and Endocrinology suggests maintaining glucose between 140-180 mg/dL once IV insulin is initiated for critically ill patients (ICU setting) 3
The American Diabetes Association recommends using validated computerized or written protocols for insulin infusion adjustments in the ICU setting 4
The Lancet Diabetes and Endocrinology advises avoiding glucose targets <110 mg/dL due to increased hypoglycemia risk 3

The American Diabetes Association recommends starting subcutaneous basal insulin 1-2 hours before stopping IV infusion when discontinuing IV insulin after glucose stabilization 4
The American Diabetes Association suggests calculating basal insulin dose as 60-80% of total daily IV insulin dose 4
The American Diabetes Association recommends using half of the 24-hour IV insulin total as long-acting basal insulin, and dividing the other half by 3 for rapid-acting insulin doses before meals 4

The American Diabetes Association strongly discourages using sliding-scale insulin alone, as it is associated with poor outcomes 5
The Lancet Diabetes and Endocrinology advises avoiding overly aggressive glucose lowering, as targets <110 mg/dL increase hypoglycemia risk and mortality 3
The American Diabetes Association recommends not stopping IV insulin abruptly, ensuring 1-2 hour overlap with subcutaneous insulin to prevent rebound hyperglycemia 4
The American Diabetes Association suggests monitoring mental status closely, as rapid changes may indicate cerebral edema (especially in younger patients) or iatrogenic complications 1
The American Diabetes Association recommends reassessing insulin regimen if glucose falls below 100 mg/dL and modifying when <70 mg/dL unless explained by missed meals 4