Management of Hypoglycaemia [Dr S Sen]

Hypoglycaemia is a serious condition and should be treated as an emergency

regardless of the patient's level of consciousness. All documented blood glucose values
<4mmol/L can be considered a hypoglycaemic event and should not be tolerated in any
patient on a regular basis. The signs and symptoms of hypoglycaemia can be variable and
a high index of suspicion is often required. Some patients experience hypoglycaemic
symptoms where the blood glucose level is not <4mmol/L. If this happens a small
carbohydrate snack can be given for symptom relief.
Hypoglycemia occurs from a relative excess of insulin in the blood and results in low
blood glucose levels. The level of glucose that produces symptoms of hypoglycemia varies
from person to person and varies for the same person under different
circumstances. Hypoglycemia is common in insulin-treated diabetic patients and may
occur in patients taking an insulin secretagogue. It may range from a very mild lowering of
glucose (60–70 mg/dl), with minimal or no symptoms, to severe hypoglycemia, with very
low levels of glucose (< 40 mg/dl) and neurological impairment.
Signs and symptoms
Symptoms of hypoglycemia can be divided into adrenergic (rapidly falling and
changing glucose levels) and neuroglycopenic (low central nervous system [CNS] glucose).
The adrenergic symptoms are inversely correlated to the developing rate of hypoglycemia,
being most pronounced with acute onsets. Adrenergic features, when present, precede
neurobehavioral features, thus functioning as an early warning system.
Inpatient team members must be alert to early adrenergic hypoglycemia signs and
symptoms, including anxiety, irritability, dizziness, diaphoresis, pallor, tachycardia,
headache, shakiness, and hunger. When symptoms occur, early treatment involves having
the patient eat simple carbohydrate. In an NPO (nothing by mouth) patient, viable
alternatives for treating early hypoglycemia include giving an intravenous (IV) bolus of
50% dextrose, or, if absent an IV, giving intramuscular glucagon. However, when
sympathetic dysfunction (e.g., diabetic autonomic neuropathy) exists or when
adrenergic blockers are being used, these signs and symptoms may be unnoticeable.
 Signs and Symptoms of Hypoglycemia

Risk Factors for Hypoglycemia

Treatment Strategies:
Mild Hypoglycaemia
Patient is conscious, orientated and able to swallow. Treat with 15-20g of quick-acting
carbohydrate such as:
• Dextrosol® 5–7tablets or
• Glucotabs® 4–5 or
• Pure fruit juice 150–200ml. Avoid fruit juice in renal failure.
Test blood glucose level after 10-15 minutes, and if still <4mmol/L, repeat above treatment
options up to 3 times. If still hypoglycaemic call a doctor and consider glucose IV (as per
severe hypoglycaemia section below) or glucagon IM 1mg (only give once).
Moderate Hypoglycaemia:

Patient is conscious and able to swallow, but confused, disorientated or aggressive. If capable
and cooperative treat as for mild hypoglycaemia above. If not capable and cooperative but
can swallow give 1.5–2 tubes of GlucoGel® (squeezed into mouth between teeth and
gums). If ineffective use glucagon IM 1mg (only give once).

Test blood glucose level after 15 minutes, and if still <4mmol/L, repeat steps above up to 3
times. If still hypoglycaemic call a doctor and consider IV glucose (as per severe
hypoglycaemic section).

Severe Hypoglycaemia
Patient is unconscious / fitting or very aggressive or nil-by-mouth (NBM). Check ABC, stop
insulin (if on IV) and contact doctor urgently. Give glucose IV over 10 minutes as:
• 20% glucose 100ml or
• 10% glucose 150ml or
• Glucagon IM 1mg (only give once). Glucagon may take up to 15 minutes to work
and may be ineffective in undernourished patients, in severe liver disease and in repeated
hypoglycaemia.
Re-check glucose after 10 minutes and if blood glucose still <4mmol/L repeat IV glucose
above.