HYPERGLYCEMIC PATHWAY IN THE EMERGENCY ROOM AND ICU

Section of Diabetes, Endocrinology, Metabolism and Nutrition

Department of Internal Medicine
Cardinal Santos Medical Center

Patient has known diabetes or random blood sugar ≥200 mg/dl in ED

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MANAGEMENT OF DKA and HHS IN ADULTS

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 INSULIN DRIP PROTOCOL FOR DKA/HHS
(This protocol is designed only for use of endocrinologists/diabetologists)

1. Give 0.1 u/kg intravenous bolus of regular/rapid acting insulin then start insulin drip
100units in 100cc plain NSS to run at 0.1 u/kg/hr

2. Adjust insulin drip using STEP 1 insulin drip titration after initiating insulin infusion

STEP 1 INSULIN DRIP:

Hourly change in blood glucose (BG) Action

BG increased Rebolus (0.1 U/kg) and double insulin

rate

BG decreased by 0-49 mg/dL/hr Increase insulin drip by 25-50%

BG decreased by 50-75 mg/dL/hr No change in insulin drip

BG decreased by >75 mg/dL/hr Decrease insulin drip by 25-50%

3. Once blood glucose is less than or equal to 250 mg/dL, shift to STEP 2 Insulin drip
titration for 24 hours

4. After 24 hours on STEP 2, may shift to STEP 3 insulin drip titration or timing as
instructed by endocrinologist/diabetologist. Increase CBG monitoring back to every
hour (if adjusted to every 2 hours from STEP 2)

*This algorithm is not intended to replace the independent medical or professional judgment of the
endocrinologist/diabetologist

ADAPTED FROM:
1 Lupsa, B.C., Inzucchi, S.E. (2014). “Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome”, in Loriaux, L. (ed.)

Endocrine Emergencies: Recognition and Treatment, Contemporary Endocrinology. New York: Humana Press, pp 24, 26.
2 The University of Texas MD Anderson Center (2018). Hyperglycemic Emergency Management (DKA/HHS) – Adult [PDF file].

Retrieved from https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-

management/clin-management-dka-or-hhs-web-algorithm.pd

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 STEP 2 INSULIN DRIP
(Target CBG 201-250 mg/dL)

• DECREASE insulin continuous IV infusion rate by half of current dose (if not
already done) then titrate every hour as follows:

GLUCOSE LEVEL DRIP ADJUSTMENT

IF decrease greater
than 100 mg/dL at Decrease infusion rate by half the current rate
one time
• Stop infusion, and give 1 vial D50W IV push
<100 mg/dL • Restart infusion at half the previous rate when glucose is
greater than 180 mg/dL on 1 measurement
• Stop infusion
100-141 mg/dL • Restart infusion at half the previous rate when glucose is
greater than 180 mg/dL on 1 measurement
141-180 mg/dL Decrease infusion rate by half the current rate
181-200 mg/dL Decrease infusion rate by 1 unit/hour
• No change in insulin drip
201-250 mg/dL • If no changes are needed for 3 consecutive measurements,
decrease monitoring to every 2 hours
• If glucose increasing, increase infusion rate by 1-2 units/hour
251-300 mg/dL
• If glucose decreasing or the same, continue current rate
• If glucose increasing, give regular/rapid insulin 6 units IV
301-350 mg/dL push and increase infusion rate by 2 units/hour
• If glucose decreasing or the same, continue current rate
• If glucose increasing, give regular/rapid insulin 12 units IV
>350 mg/dL push and increase infusion rate by 2 units/hour
• If glucose decreasing or the same, continue current rate

*This algorithm is not intended to replace the independent medical or professional judgment of the
endocrinologist/diabetologist

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 STEP 3 INSULIN DRIP
(Target CBG 141-180 mg/dL)

GLUCOSE LEVEL DRIP ADJUSTMENT

IF decrease greater
than 100 mg/dL at Decrease infusion rate by half the current rate
one time
• Stop infusion, give 1 vial D50W IV push
<80 • Restart infusion at half the previous rate when glucose is
greater than 140 mg/dL on 1 measurement
• Stop infusion, give ½ vial D50W IV push
80-100 mg/dL • Restart infusion at half the previous rate when glucose is
greater than 140 mg/dL on 1 measurement
101-120 mg/dL Decrease infusion rate by half the current rate
121-140 Decrease infusion rate by 1 unit/hour
• No change in insulin drip
141-180 mg/dL • If no changes are needed for 3 consecutive measurements,
decrease monitoring to every 2 hours
• If glucose increasing, increase infusion rate by 1 unit/hour
181-200 mg/dL
• If glucose decreasing or the same, continue current rate
• If glucose increasing, increase infusion rate by 1.5 units/hour
201-250 mg/dL
• If glucose decreasing or the same, continue current rate
• If glucose increasing, increase infusion rate by 2 units/hour
251-300 mg/dL
• If glucose decreasing or the same, continue current rate
• If glucose increasing, give regular/rapid insulin 6 units IV
301-350 mg/dL push and increase infusion rate by 2 units/hour
• If glucose decreasing or the same, continue current rate
• If glucose increasing, give regular/rapid insulin 12 units IV
>350 mg/dL push and increase infusion rate by 2 units/hour
• If glucose decreasing or the same, continue current rate
*This algorithm is not intended to replace the independent medical or professional judgment of the
endocrinologist/diabetologist

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CONTINUOUS INSULIN INFUSION PROTOCOL

Adapted from the Texas Insulin Protocol for CRITICALLY-ILL PATIENTS

1. Adjusting the Infusion:

u Algorithm 1: Start here for most patients.

Algorithm 2: For patients not controlled with Algorithm 1, or start here if s/p
u

CABG, solid organ or islet cell transplant, receiving glucocorticoids etc. or patient
with diabetes receiving >80 units/day of insulin as an outpatient.

Algorithm 3: For patients not controlled on Algorithm 2. NO PATIENT STARTS

u

HERE without authorization from the endocrine .

Algorithm 4: For patients not controlled on Algorithm 3. NO PATIENT STARTS

u

HERE

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2. Moving from Algorithm to Algorithm:

u Moving Up: When glucose remains outside the target range after titrating insulin

u Moving Down: When glucose is <70 mg/dL x 2 or decreases >60 mg/dl in 1 hour

3. Patient Monitoring:

Hourly venous (lab) determinations until glucose <450 mg/dL; then capillary
u

glucose (finger sticks) q 1hour until glucose is within goal x 4 hours; then every 2
hours x 4 hours; If stable, decrease monitoring to every 4 hours

Hourly monitoring indicated for critically ill patients even if the glucose is stable
u

In hypotensive patients (BP <80/60), capillary glucose values may be inaccurate.

u

Obtain

venous blood for glucose determinations

If any of the following occur, temporarily resume hourly glucose monitoring, until
u

glucose is again stable (2–3 consecutive values within target range):

Any change in insulin infusion rate

Significant changes in clinical condition
Starting or stopping pressor or steroid therapy
Starting or stopping dialysis
Starting, stopping or changing rates of TPN, PPN or tube feedings

4. Treatment of Hypoglycemia (Glucose <60 mg/dL)

u Discontinue insulin drip AND

Give D50W IV Glucose 40–60 mg/dL 12.5 g (1/2 vial) Glucose <40 mg/dL 25.0 g
u

(1vial)

Recheck glucose every 15–30 minutes and repeat D50W IV as above. Restart
u

insulin drip, one algorithm lower, when glucose >80 mg/dL x 2

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Important hyperglycemia management reminders:
• A complete history and physical examination is important.
• Assess the hydration and electrolyte status, blood glucose, acidosis and
calculate anion gap
• All diabetic patients must placed on capillary point of care –
• Critically-ill patients: On Continuous intravenous insulin drip protocol every
hourly until stable to q 2hours
• Non-critically-ill patients: on Basal Bolus
• and on diet (oral) -TID ac and HS (4X/day)
• on nutrition support, enteral or parenteral, CBG every 4 hours
• Target goals for:
• Critically-ill patients: goal of majority of ICU patients 140 -180 mg/dl or 7.8
mmol/L to 10.0 mmol/L, avoid levels <6.1 mmol/L (<110mg/dl) or greater
than 10mmol/L (>180 mg/dl); but in selected ICU patients (surgical
patients or patients with stable glycemic control) goal of 110-140 mgs/dl
(6.1 – 7.8mmol/L) or as set by attending endocrinologist / diabetologist
• Non-critically-ill patients: target pre-meals level of ≤ 140 mgs/dl and
random levels of 180 mgs/dl; higher levels are acceptable in the elderly,
terminally ill patients and patients with history of hypoglycemia
• AVOID Hypoglycemia!!! Lower the total basal and prandial insulin dose if
levels fall between 70-100 mgs/dl in selected patients
• Medical Nutrition therapy should be initiated in hospitalized hyperglycemic
patients and often requires specialized insulin regimens.
• Total Caloric requirements of hospitalized patients, who are still in catabolic
phase, should be calculated using a lower stress factor of 25-28 kcal/kg /day to
provide lower calories but with adequate or higher protein requirement
calculated at 1.0-1.8 g/kg IBW as long as the kidney function is normal
• For BMI > 30 kg/m2 provide 2.0 g/IBW kg/day;
• BMI > 40 provide 2.5g / kg IBW/ day
• Transition from CII to SC insulin administration requires overlap of basal insulin
at least 1- 2 hours before discontinuation of insulin drip.
• Basal bolus dose is determined by taking 80% of the total 24h insulin dose
in 24 hour and split 50-50 to basal and prandial dose.
• For patients with stress hyperglycemia and normal HbA1c, who have been
on CII in the ICU and requires 1-2 U/hour only at the time of transition,
may not require scheduled SC insulin regimen. Patients may be started
on correction insulin to determine if scheduled insulin is required.
• If patient develops hypoglycemia < 70 mgs/dl, hold insulin drip
• Give Dextrose 50% in water IV for conscious patient give ½ vial (25 ml ~
12.5 gm glucose) and 1 vial for unconscious patient (50 ml~ 25 gms
glucose)
• Repeat CBG / capillary point of care 20-30 mins after IV glucose
administration. If repeat cbg is < 70 mg/dl repeat 25 ml of D50W

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• Monitor electrolytes - Na, K, Cl, Ionized calcium , phosphorous every 4 hours or
as ordered by attending endocrinologist/ diabetologist
• Diabetes education – comprehensive diabetes education module , nutrition
education and counselling module and insulin module should be provided to
both patient and family once patient is stable or about to be discharged.

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