Management of Severe Hyperglycemia

Initial Assessment

The American Diabetes Association recommends evaluating signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) by measuring serum ketones, arterial pH, bicarbonate, osmolality, and mental status in patients with severe hyperglycemia 1
Assessing the degree of dehydration, which is often more severe in HHS (deficit of 9 liters or 100-200 ml/kg of total body water), is crucial in the initial assessment 1
Identifying potential precipitating factors such as infection, missed insulin doses, medications (corticosteroids, diuretics, beta-blockers), or intercurrent illness is essential 2, 1
Monitoring altered mental status, which can indicate cerebral edema, a rare but potentially fatal complication, is vital 1
Evaluating sarcopenia as a possible complication of uncontrolled diabetes over the long term is necessary 3

The American College of Cardiology recommends monitoring cardiac arrhythmias continuously during the acute phase 4
Administering a bolus of regular insulin intravenously at 0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/h, is a recommended treatment for severe hyperglycemia 1
The American Diabetes Association suggests establishing a glucose target of 140-180 mg/dl to avoid both hyperglycemia and hypoglycemia 4, 6
Monitoring and replacing potassium, as total body deficits in hyperglycemic crises often include 4-6 mEq/kg of potassium, is crucial 1

Initiating aggressive fluid replacement with isotonic saline solution (0.9% NaCl) at 15-20 ml/kg/hour during the first hour to restore circulatory volume and tissue perfusion is recommended 1
Correcting fluid deficits within the first 24 hours, with an induced change in serum osmolality not exceeding 3 mOsm/kg/h, is essential 1

Once the patient is stable, with consistent glucose values for at least 4-6 hours, normal anion gap, resolution of acidosis, hemodynamic stability, and a stable nutritional plan, transitioning to subcutaneous insulin can be done 6
Calculating subcutaneous insulin requirements based on the average amount of insulin infused during the 12 hours prior to transition is necessary 6

Providing education on sick-day management, including when to contact healthcare providers, blood glucose targets, use of supplemental insulin during illness, and maintaining hydration, is vital 1
Emphasizing the importance of never stopping insulin during illness is crucial 1
Instructing on the importance of frequent glucose monitoring is necessary 8, 7

Monitoring the response to insulin and fluid therapy through frequent glucose checks is essential 6
Evaluating the resolution of symptoms such as headache and polydipsia is necessary 3
Vigilance for potential complications such as hypoglycemia, hypokalemia, and cerebral edema is crucial 1
Developing a long-term plan for diabetes management, including strategies to prevent sarcopenia, is essential 3, 7