DRG Category: 640
Mean LOS: 4.5 days
Description: Medical: Miscellaneous Disorders of Nutrition, Metabolism, Fluids, and Electrolytes With Major Complication or Comorbidity
Hypoglycemia occurs when the blood glucose falls below 50 mg/dL. Normal blood glucose values range between 70 and 100 mg/dL. A series of complex physiological responses is set off when a patient develops a low level of blood glucose. The most dramatic is the sympathetic nervous system (SNS) or adrenergic response, which is primarily the result of epinephrine. Epinephrine stimulates the liver to convert glycogen into glucose to support the falling serum glucose. In addition, the reticular activating system creates a state of alertness and wakefulness (fight-or-flight reaction).
Cerebral dysfunction occurs when the central nervous system (CNS) is deprived of glucose for cellular needs. In contrast to muscle and fat cells in the body that can break down amino and fatty acids for energy, the brain cells depend on glucose for energy. When the liver's supply of glycogen is depleted and no replacement is available, brain damage results. Prolonged periods of hypoglycemia can lead to complications such as coma, permanent brain damage, and death.
Causes can best be understood by breaking them into the nondiabetic and diabetic categories. In the nondiabetic patient, there are four classifications of hypoglycemia: organic, iatrogenic, reactive, and gestational. Organic hypoglycemia is caused by liver diseases such as hepatitis, cirrhosis, liver cancer, and insulin-secreting tumors. Iatrogenic hypoglycemia is associated with consumption of alcohol and reactions to drugs such as beta-adrenergic blockers and sulfonylureas, the two most common for this problem. Reactive hypoglycemia is caused by an adrenergic response that is triggered within 5 minutes of meal consumption in susceptible individuals. Symptoms are transient. Reactive hypoglycemia occurs in approximately 75% of all spontaneous hypoglycemic reactions. Gestational hypoglycemia occurs during pregnancy and occurs most often in people with preexisting conditions.
Hypoglycemia occurs more often in diabetic patients who are receiving insulin or oral hypoglycemic agents. Usually, this reaction is the result of an imbalance between insulin/hypoglycemic agent intake and exercise or food intake. In the patient with diabetes mellitus (DM), hypoglycemia occurs usually for the following reasons: medication errors (too much insulin or hypoglycemic agent), diet changes (too little food intake or omission), and activity level (increase in activity in relation to medication and food intake). Other causes in the diabetic patient include alcohol consumption, drugs, emotional stress, and infections.
There are several familial forms of hyperinsulinemic hypoglycemia, inherited in autosomal dominant and recessive patterns. Mutations in nine genes have so far been shown to cause congenital hyperinsulinism: ABCC8, KCNJ11, HADH, GLUD1, GCK, HNF1A, HNF4A, SLC16A1, and UCP2. One form has been linked to a mutation in the human insulin receptor gene. Persistent hyperinsulinemic hypoglycemia of infancy is a rare disorder that often follows an autosomal recessive inheritance pattern. It is usually due to dysregulation of negative feedback of insulin secretion by low glucose levels.
People with diabetes and older adults are at higher risk for hypoglycemia than other people. Older adults may have fewer symptoms of hypoglycemia, and the symptoms may appear at a lower threshold of blood glucose. Reactive hypoglycemia, recurrent episodes of symptomatic hypoglycemia occurring within 4 hours after a high-carbohydrate meal, is more common in females than males. It is also more common in overweight and obese persons who are insulin resistant. Reactive hypoglycemia occurs in people with and without diabetes.
Ethnicity, race, and sexual/gender minority status have no known effect on the risk for hypoglycemia.
Hypoglycemia can result because of the treatment for DM or from other conditions. The prevalence of DM is increasing dramatically. The World Health Organization considers DM as a global epidemic with the number of people with DM exceeding 422 million. The International Diabetes Federation states that by 2030 the number will exceed 500 million, and the countries with the most cases include the most populous countries of the world, such as China and India as well as Western Europe. Experts estimate that in the developing world, large increases will occur in sub-Saharan Africa, Latin America, and the Middle East.
PLANNING AND IMPLEMENTATION
Collaborative
The immediate management is to maintain a patent airway, regular breathing, and adequate circulation and to replace the glucose to restore the energy source for cells. If the patient is alert, has a patent airway, and can safely ingest oral carbohydrates, you may provide a cup of milk, fruit juice without additives, a granola bar, or cheese and crackers. Approximately 15 to 20 g of carbohydrates can be found in each of the following foods: 4 ounces of orange or grapefruit juice or regular soda; 8 ounces of milk; three graham crackers; 2 to 3 teaspoons of honey; or 6 to 10 hard candies. Oral glucose and sugar-containing fluids are effective but may lead to hyperglycemia. The blood glucose should be tested again after 15 minutes and treated again if it is less than 70 to 75 mg/dL.
The unconscious, hospitalized patient with severe hypoglycemia or the patient with suspected medication overdose needs a source of IV glucose immediately. Occurring simultaneously with glucose administration, if needed, is management of the airway and breathing with endotracheal intubation and breathing with a manual resuscitator bag. Usually, with restoration of airway, breathing, and serum glucose, the patient does not have circulatory instability, but the patient may receive IV fluid hydration and inotropic drugs to maintain circulation. If the patient is receiving insulin by continuous infusion either in a crystalloid or in total parenteral nutrition, the infusion is tapered or turned off, and the physician reevaluates the dose.
Once the patient regains consciousness, the oral intake of carbohydrates is increased to maintain the serum glucose. Whether in the hospital or at home, the healthcare provider needs to conduct an aggressive search to identify the precipitating cause of the hypoglycemic episode and to institute preventive strategies.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| 50% dextrose | IV 25–50 mL, followed by an infusion of D5W or D10W to maintain a blood glucose of 100 mg/dL | Sugar; antihypoglycemic | Supplies a source of carbohydrate that can be immediately converted to glucose |
| Glucagon | 1 mg IM or SC | Antihypoglycemic; promotes hepatic glycogenolysis and gluconeogenesis, stimulates production of cyclic adenosine monophosphate | Treats hypoglycemia if the person cannot maintain oral intake and if IV access is not available; note that the drug may cause vomiting |
Note: Diazoxide (Hyperstat), an inhibitor of insulin secretion, may be used rarely as an adjunct to a glucose infusion because it increases hepatic glucose output and decreases cellular glucose uptake.
Independent
Assessment and management of airway, breathing, and circulation is the highest priority. Never force an unconscious or semiconscious patient to drink liquids because of the risk of aspiration into the lungs. Continue to repeat the oral intake of carbohydrates until the blood glucose rises above 100 mg/dL and administer the next meal as soon as possible. If the next scheduled meal is not ready for more than 30 minutes or longer, provide the patient with a combination of carbohydrates and protein, such as ½ cup milk, 1 ounce of cheese, and three saltine crackers.
Teach the patient and family prevention, detection, and treatment of hypoglycemia. Encourage a daily exercise, diet, and medication regimen on a consistent basis. Remind the patient to consume extra foods before increased exercise and to carry a rapid-absorbing carbohydrate at all times. Teach the patient and significant others to keep glucagon available in the home or at work or school. Instruct coworkers, teachers, and neighbors how to treat hypoglycemia.
Evidence-Based Practice and Health Policy
Chalew, S., Kamps, J., Jurgen, B., Gomez, R., & Hempe, J. (2020). The relationship of glycemic control, insulin dose, and race with hypoglycemia in youth with type 1 diabetes. Journal of Diabetes and Its Complications, 34, 1–6.
- The authors aimed to study whether Black pediatric patients with type I diabetes may be prescribed higher daily doses of insulin than White pediatric patients, putting them at greater risk for hypoglycemia. They performed a retrospective analysis of 88 cases studying social and environmental factors, changes of insulin dose, hemoglobin (Hb)A1c levels, and episodes of hypoglycemia.
- Age, duration of diabetes, and body mass index were similar in both groups. Black patients had higher levels of HbA1c, and insulin dose increased with increasing HbA1c and mean blood glucose. The authors found no differences in Black and White patients with respect to the occurrence of hypoglycemia and insulin dosing.