Hyperglycemia: How High = Admit?

[docB]

So I had a very diabetic day a few shifts back. I had to interact with several primaries about diabetics with hyperglycemia. That shift drove home the point that different docs deal with it very differently.

So, for the sake of discussion, when you have a known diabetic with a blood sugar of X and no evidence of DKA (no gap, no acetone), no evidence of infection and who is able to tolerate PO do you admit? I'm talking glucose of 500, 700 or 1000 here. I've gotten reactions ranging from "700? Put her in the ICU on a drip!" to "Yeah 700 is ok. Give her 15 units of reg SQ and tell her to see me in a few days."

Is there a magic number?

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[BADMD]

So I had a very diabetic day a few shifts back. I had to interact with several primaries about diabetics with hyperglycemia. That shift drove home the point that different docs deal with it very differently.

So, for the sake of discussion, when you have a known diabetic with a blood sugar of X and no evidence of DKA (no gap, no acetone), no evidence of infection and who is able to tolerate PO do you admit? I'm talking glucose of 500, 700 or 1000 here. I've gotten reactions ranging from "700? Put her in the ICU on a drip!" to "Yeah 700 is ok. Give her 15 units of reg SQ and tell her to see me in a few days."

Is there a magic number?

For me, the issue is really going to be more of electrolytes and volume depletion. I routinely see people in the 500s. A few liters of IV fluids, re-establish their orals and maybe a touch of sub-Q insulin if they are insulin dependent, then OTD when they get around 200-250. Yeah, 700 is high, but nothing magic occurs between 500 and 700. I can see all kinds of arguments about shifting tonicity and the like, but I've never seen it from giving a a few liter bolus then a few hundred an hour. I might admit someone to a floor or obs if I thought it was going to take more 6-8 hours to get their sugar under control safely.

Now an insulin drip...that will shift someone's tonicity.

 

[southerndoc]

Depends on how they look. I've seen people look like crap at 700, and others look like a rose at 800. If they came in complaining of a diabetic-related complaint, I'm more likely to admit than if they came in with something completely unrelated (trauma, etc.).

 

[Seaglass]

Yeah, it depends on how they look and when they can be seen again - if it's a non-compliant type patient I'm more likely to admit so they don't roll back in 2-3 days in DKA and get admitted for 2 days instead of what could have been a 23 hour obs for fluids and insulin.

 

[WilcoWorld]

I certainly don't have a magic number.

As mentioned above, and as I'm sure noone needs to tell DocB - the underlying cause is huge in my dispo decision. I'm much less likely to admit someone who's simply non-compliant than someone who also has concurrent infection or the like. I'm also more likely to admit a type 1 with prior episodes of DKA than a type 2 who doesn't seem at all bothered by the hyperglycemia.

In any case, I do like to see the glucose at or below 250 before I send them home, because that tells me that the beans will be able to start working again instead of just being continuously diuresed by a Willy Wonka river of sugar flowing through them. I don't know of any data showing that this will reduce bounce-backs, but it seems to make physiologic sense to me.

 

[PedsEndoSec]

As someone who works in endo, I'd say it depends on several factors, most of which were stated above...

1) Does the patient look/feel ill?
2) Does the patient have a hx of noncompliance?

And, of course, whether or not the patient is a new onset. We admit *all* new onsets for education, but since we're in peds endo we can do that. 😀

Anyway, we don't generally advise admission for hyperglycemia without DKA - our hospitals are short enough on beds as it is. We might advise to keep them in the ER for a while to make sure their BG comes down, but unless they're a noncompliant family who won't properly take care of the high sugar (which is somewhat likely, or else it never would have gotten that high in the first place), we wouldn't do an admit. Hell, we don't even send patients to the hospital for a high blood sugar unless they have vomiting or urine ketones (or are out of ketostix, heh). We just have them correct at home.

Of course, I don't work in an ER, but there's something from the primary care side for you. 🙂

 

[EM_Rebuilder]

I had a 1548 the other day....seizing no less.

He got the night in the unit.


My favorite recent DM story was my patient the other day that came in 'cause her sugar was high' at 500 at home. She felt funny, she called her neighbor, who brought her some orange juice she still felt funny so she came in. She got a few liters of fluid, 10 of Regular, a BIG TALKING TO about high vs low sugar, and a swift kick out the door at the Mississippi goal of less than 250 glucose...


To answer your question, I dunno that IM would take a magic number here. I am sure they would be more particular on how the patient looks. Although, this is MS and the sweet tea drinkers probably live at 600-800....

 

[roja]

Absolutely no magic number. I don't believe in magic numbers.

It all depends on the person. Coming from a place in medical school where 85% of people have DM, I am pretty comfortable with high sugars.

If necessary, I make sure they aren't in DKA. I make sure there isn't some underlying cause of thier elevated sugar. (infection, etc).

If they aren't wierdly symptomatic, then I may give IVF. usually someone has given insulin (really only think this is necessary if they are insulin dependent).

I have no magic 'get the number below'. If they aren't in DKA, no real symptoms, and are basically noncompliant with diet and/or meds, I send them home.

I tend to feel that the 'get below X' just makes us as MD's feel like we are doing something. We aren't really. The sugar is just going to go back up once they leave and go eat. They need good follow up.....I usually mention blindness, amputation etc etc..... as needed.

 

[DrQuinn]

Anyway, we don't generally advise admission for hyperglycemia without DKA - our hospitals are short enough on beds as it is. We might advise to keep them in the ER for a while to make sure their BG comes down, but unless they're a noncompliant family who won't properly take care of the high sugar (which is somewhat likely, or else it never would have gotten that high in the first place), we wouldn't do an admit. Hell, we don't even send patients to the hospital for a high blood sugar unless they have vomiting or urine ketones (or are out of ketostix, heh). We just have them correct at home.

Of course, I don't work in an ER, but there's something from the primary care side for you. 🙂

thanks for the insight PedsEndoSec... its good to have non-EM-non-flaming comments here and there!

No magic number, but I do check a UA on them and a gap. Thankfully we have an ISTAT lab in the ED so checking labs is pretty painless for us. I try not to start an IV if I don't have to (my personal philosophy), so I use Aspart and po water, check a UA, check a gap, and just get a trend downwards. This is if they look great.

That being said< I have been out of residency for ~ 27 months now and I really haven't seen anyone who came in because their BS were high (that weren't in DKA) and they felt bad. Usually they feel great. I've even seen a few DKAers who look pristine.

Q

 

[dragonfly99]

I couldn't name a number where I'd admit. Lots of the 400's-500's can get their med(s), or one shot of insulin, +/- IV fluids, then go home. Just make SURE they aren't in DKA, and make sure they have followup. I personally haven't seen anyone with a 1000 glucose who didn't need IV fluids or have any other electrolyte abnormality...but I don't work the ER that often. Remember Type II can be hyperosmolar and get sick even though not in DKA....