Guidelines Hypoglycemia

Question 1

Mild signs and symptoms of hypoglycaemia

Answer 1

Patient conscious and able to swallow with hypoglycaemia signs and symptoms

Question 2

Moderate signs and symptoms of hypoglycaemia

Answer 2

Moderate: Patient conscious and able to swallow but in need of assistance + Hypoglycemia symptoms

Question 3

Severe signs and symptoms of hypoglycaemia

Answer 3

Severe: Patient unconscious, unable to swallow and needs external
assistance
* Unconscious
* Unresponsive
* Fitting/Seizure

Question 4

What is hypoglycaemia defined as

Answer 4

Blood glucose < 4 mmols

Question 5

What to do in patients with
hypoglycaemia with mild signs and symptoms of

Answer 5

Administer 10-20g fast acting glucose*
* 1-2 tubes 40% glucose gels
* 3-5 glucose tablets (GlucoTabs) (4g per tablet)
* 1 x 59ml Glucose Liquid
Blast
- Lift® glucose liquid (previously Glucojuice®)
- Fruit juice or sugar mixed in water if not available
- If necessary, repeat treatment after 15 minutes, up to a maximum of 3 treatments in total
- Hypoglycaemia which does not respond (blood-glucose concentration remains below 4 mmol/litre after 30–45 minutes or after 3 treatment cycles), should be treated with intramuscular glucagon or glucose 10% intravenous infusion

Question 6

Which hypoglycaemic patients should be treated?

Answer 6

Any patient with a blood-glucose concentration less than 4 mmol/litre, with or without symptoms, and who is conscious and able to swallow, should be treated with a fast-acting carbohydrate by mouth

Question 7

Which drugs are more likely to cause hypoglycemia in diabetes therapy?

Answer 7

• Hypoglycemia is the most common side effect o insulin and sulfonylureas
• Metformin hydrochloride, pioglitazone, the dipeptidylpeptidase-4 inhibitors (gliptins), sodium-glucose co-transporter-2 inhibitors, and glucagon-like peptide-1 receptor agonists, prescribed without insulin or sulfonylurea therapy, are unlikely to result in hypoglycaemia

Question 8

Should chocolate and sweets be given to hypoglycaemic patients in an attempt to raise their sugar levels?

Answer 8

Chocolates and biscuits should be avoided if possible, as they have a lower sugar content and their high fat content may delay stomach emptying.

Question 9

What to do in hypoglycaemic patients with moderate symptoms?

Answer 9

• Administer 2 tubes of Glucogel*/**
  (10g glucose per tube)
  Ensure that gag reflex is present
• Follow rest of protocol for mild symptoms

Question 10

What do in hypoglycaemic patients with sever symptoms?

Answer 10

• Hypoglycaemia which causes unconsciousness is an emergency. Patients who are unconscious, having seizures, or who are very aggressive, should have any intravenous insulin stopped, and be treated initially with glucagon. If glucagon is unsuitable, or there is no response after 10 minutes, glucose 10% intravenous infusion, or alternatively glucose 20% intravenous infusion should be given.
• If glucagon is not effective after 10 minutes, glucose 10% intravenous infusion should be given

Question 11

Glucose 50 % infusion in severe hypoglycemia

Answer 11

Glucose 50% intravenous infusion is not recommended as it is hypertonic, thus increases the risk of extravasation injury, and is viscous, making administration difficult.

Question 12

What to do once patient is not hypoglycaemic anymore

Answer 12

A long-acting carbohydrate should be given as soon as possible once the patient has recovered and their blood-glucose concentration is above 4 mmol/litre (minimum 15g)(e.g. two biscuits, one slice of bread, fruit juice, banana, 200–300 mL of milk (not soya or other forms of ‘alternative’ milk, e.g. almond or coconut), or a normal carbohydrate-containing meal if due)

Question 13

What to do once patient is not hypoglycaemic anymore if they have received glucagon

Answer 13

Patients who have received glucagon require a larger portion of long-acting carbohydrate to replenish glycogen stores (e.g. four biscuits, two slices of bread, 400–600 mL of milk (not soya or other forms of ‘alternative’ milk, e.g. almond or coconut), or a normal carbohydrate containing meal if due)

Question 14

What to give hypoglycaemic patients who are nil by mouth?

Answer 14

Glucose 10% intravenous infusion should be given to patients who are nil by mouth

Question 15

Should insulin be given following hypoglycaemic episode?

Answer 15

• If an insulin injection is due, it should never be omitted; however, a review of the usual insulin regimen may be required
• Patients who self-manage their insulin pump may need to adjust their pump infusion rate

Question 16

How long should blood glucose be monitored following hypoglycaemic episode?

Answer 16

Blood-glucose monitoring should be continued for at least 24–48 hours.

Question 17

When could we expect longer lasting hypoglycaemic episodes in diabetic patients?

Answer 17

Hypoglycaemia caused by a sulfonylurea or long-acting insulin, may persist for up to 24–36 hours following the last dose, especially if there is concurrent renal impairment.

Question 18

Alcoholic hypoglycaemic patients management

Answer 18

In alcoholic patients, thiamine supplementation should be given with, or following, the administration of intravenous glucose to minimise the risk of Wernicke’s encephalopathy.

Question 19

Names of 40% glucogels

Answer 19

Glucogel, Dextrogel, Rapilose

Question 20

Glucagon dosage in hypoglycemia

Answer 20

1mg

Question 21

Adjustments in sulphonylureas in hypoglycemic patients

Answer 21

If severe hypo’s stop until reviewed by diabetes team.
If mild hypos, halve the dose of Sulphonylurea

Question 22

Symptoms of hypoglycemia with long standing diabetes

Answer 22

• In the elderly and patients who have had diabetes for a number of years, classic symptoms may be absent and the patient may
  be unaware that they are having a hypo.
• The other way is true too, patients who have diabetes can present with symptoms of hypoglycemia at relatively higher serum glucose levels ( This phenomenon is called “pseudohypoglycemia” because the serum glucose may be within normal range despite symptom presentation)
• Chronic hyperglycaemia alters the “set point” in which neuroglycopenic/neurogenic symptoms become apparent.

Question 23

What can signs and symptoms of Hypoglycemia be classified into and how do they arrise?

Answer 23

Can be classified as either neuroglycopenic: or neurogenic. Neuroglycopenic signs and symptoms are signs and symptoms that result from direct central nervous system (CNS) deprivation of glucose.
Neurogenic symptoms and signs arise from sympathoadrenal involvement (either norepinephrine or acetylcholine release) in response to perceived hypoglycemia.

Question 24

Neuroglycopenic symtpoms and signs

Answer 24

These include behavioural changes, confusion, fatigue, difficulty concentrating, seizure, coma, and potential death if not immediately corrected

Question 25

Neurogenic symptoms and signs in hypoglycemia

Answer 25

Neurogenic signs and symptoms can be adrenergic (including tremors, palpitations, and anxiety) or cholinergic (including hunger, diaphoresis, paresthesias).