Management of Hyperglycemia in Diabetic Patients

Initial Assessment and Management

The American Diabetes Association recommends obtaining immediate blood glucose, venous blood gases, electrolytes, blood urea nitrogen (BUN), creatinine, calcium, phosphorous, and urine analysis to assess for ketosis and other metabolic abnormalities in diabetic patients with hyperglycemia 1
The American Diabetes Association suggests checking for ketones in urine or blood to rule out diabetic ketoacidosis (DKA) in diabetic patients with hyperglycemia 1
The American Society of Anesthesiologists recommends transferring patients with ketones present (ketonuria 2+ or ketonaemia ≥1.5 mmol/L) to ICU for intravenous insulin infusion therapy 2
The American Diabetes Association recommends assessing hydration status and initiating fluid replacement with normal saline at 1.5 times maintenance requirements (approximately 5 ml/kg/h) in diabetic patients with hyperglycemia 1

The American Association of Clinical Endocrinologists recommends initiating intravenous insulin infusion at 0.1 U/kg/hour for patients with severe hyperglycemia 3
The American Association of Clinical Endocrinologists suggests targeting a blood glucose range of 150-250 mg/dL initially in patients with severe hyperglycemia 3
The American Diabetes Association recommends monitoring blood glucose every 1-2 hours until values and insulin infusion rates are stable, then every 4 hours in patients with hyperglycemia 3
The American Association of Clinical Endocrinologists recommends adjusting insulin infusion rate according to algorithm:
- If glucose >250 mg/dL: increase infusion by 1-2 U/hour
- If glucose 150-250 mg/dL: maintain same rate
- If glucose <150 mg/dL: decrease by 0.5-1 U/hour 3

The American Diabetes Association recommends monitoring serum potassium every 4-6 hours initially, as insulin therapy lowers serum potassium in patients with hyperglycemia 1, 3
The American Diabetes Association suggests including potassium in intravenous fluids (1/3 KPO4 and 2/3 KCl or Kacetate) in patients with hyperglycemia 1
The American Diabetes Association recommends monitoring venous pH and anion gap to track resolution of acidosis if present in patients with hyperglycemia 1
The American Association of Clinical Endocrinologists recommends avoiding rapid changes in blood glucose (not more than 50-75 mg/dL/hour) to prevent neurological complications in patients with hyperglycemia 3

The American Diabetes Association recommends continuing intravenous insulin until blood glucose is <200 mg/dL, serum bicarbonate is ≥18 mEq/L, and venous pH is >7.3 (if DKA was present) in patients with hyperglycemia 1
The American Association of Clinical Endocrinologists suggests calculating subcutaneous insulin requirements based on the total dose of intravenous insulin administered in the previous 12-24 hours in patients with hyperglycemia 3
The American Diabetes Association recommends transitioning to a basal-bolus insulin regimen rather than sliding scale insulin alone, which is discouraged in patients with hyperglycemia 4
The American Association of Clinical Endocrinologists recommends maintaining the intravenous insulin infusion for 1-2 hours after initiating subcutaneous insulin to ensure adequate insulin levels in patients with hyperglycemia 3

The American Society of Anesthesiologists recommends scheduling follow-up with primary care physician within one month for patients with HbA1c <8% 5
The American Society of Anesthesiologists suggests arranging consultation with a diabetologist for patients with HbA1c between 8-9% 5
The American Society of Anesthesiologists recommends considering referral to a diabetologist before discharge for possible specialized care for patients with HbA1c >9% or persistent hyperglycemia (>250 mg/dL) 5

The American Diabetes Association recommends not relying on sliding scale insulin alone without basal insulin, as this approach is ineffective and discouraged in patients with hyperglycemia 4
The American Diabetes Association suggests not using nitroprusside method (urine ketones) to monitor response to therapy in DKA, as β-hydroxybutyrate (the predominant ketone) is not measured by this method 1
The American Diabetes Association recommends avoiding rapid correction of glucose to prevent complications such as cerebral edema in patients with hyperglycemia 1, 3
The American Association of Clinical Endocrinologists recommends being vigilant for hypoglycemia during insulin therapy, though the target range of 150-250 mg/dL reduces this risk in patients with hyperglycemia 3