Hyperglycemia Management

Hyperglycemia is usually defined as any blood glucose >150mg/dL. However, the threshold at which hyperglycemia is treated varies based on the individual patient and their individualized glycemic targets.

For critically ill diabetic patients in the PICU, studies have found that tight glycemic control (80-110mg/dL) did not improve clinical outcomes but led to a greater incidence of hypoglycemia than more relaxed glycemic targets of 80 to 150-180mg/dL. (Zhao et al., 2018)(Agus et al., 2017)

Symptoms of hyperglycemia were discussed in Unit 1.

• Eating carbohydrates AND excessive protein-rich “carb-free” foods
• Over-treatment of a low blood sugar
• Not taking enough insulin for carbohydrate coverage or hyperglycemia correction
• Not taking insulin 15-20 minutes before eating
• Forgetting to take insulin
• Sedentary activity
• Stress
• Illness or infections
• Injury or surgery
• Medications (such as steroids)

It is normal in diabetes to have post-prandial spikes of hyperglycemia. However, blood sugar should return to a normal range within 2-3 hours after rapid-acting insulin administration if the patient gets the appropriate amount of carbohydrate coverage (and hyperglycemia correction if needed). A mismatch in the timing of insulin delivery can also lead to higher post-prandial meal spikes.

Long-standing hyperglycemia leads to endothelial damage and destruction of the microvasculature and microvasculature of the cardiovascular system.  Explore the following figure to learn more about the long-term consequences of diabetes and how we screen for these.

1. The correction factor is used to determine if insulin is needed for correction of hyperglycemia before protocolized times (mealtimes and 0300)
2. Hyperglycemia correction can be considered at non-protocolized times for severe hyperglycemia but should be discussed with the on-call pediatric endocrinology provider first.
   • If non-protocolized hyperglycemia correction is to be given, a one-time EPIC order needs to be placed.
3. Never give hyperglycemia correction within three (3) hours of another hyperglycemia correction OR ketone correction.
4. Always check for ketones when BG is >240mg/dL and, if present, correct ketones BEFORE considering correction of hyperglycemia.

1. Zhao, Y., Wu, Y. & Xiang, B. Tight glycemic control in critically ill pediatric patients: a meta-analysis and systematic review of randomized controlled trials. Pediatr Res 83, 930–935 (2018). https://doi.org/10.1038/pr.2017.310
2. Agus, M. S. D., Wypij, D., Hirshberg, E. L., Srinivasan, V., Faustino, E. V., Luckett, P. M., . . . Nadkarni, V. M. (2017). Tight Glycemic Control in Critically Ill Children. New England Journal of Medicine, 376(8), 729-741. doi:10.1056/NEJMoa1612348

Figures:

1. Figure 1: This figure was created by Dr. Tuttle using the following icons: “jar icons” by Nikita Golubev at Flaticon.com and “sugar blood diabetes” by Pike Picture from Noun Project (CC BY 3.0).