Introduction
This section gives guidance and links on the management of inpatient hypoglycaemia. Hypoglycaemic episodes are when the capillary blood glucose (CBG) falls below 4mmol/l and are often referred to as “Hypos”.
Diabetes emergencies - Hypoglycaemia
Hypoglycaemic episodes are common, particularly with Type 1 diabetes but also occur in patients with Type 2 diabetes treated with insulin or sulphonylureas.
Hypoglycaemia in Type 2 diabetes is more common in the elderly and those with renal impairment.
Hypoglycaemia should be excluded in any person with diabetes who is unwell, drowsy, unconscious, unable to co-operate or presenting with aggressive behaviour or seizures.
Hypoglycaemia is a diabetes emergency
Think–is this patient at risk of hypoglcaemia? How can you reduce the risk of hypoglycaemia? And if hypoglyceamia does occur treat immediately to minimize risk of severe harm or death.
If unsure ask for help either from diabetes team or a senior doctor
Establishing the Diagnosis of Hypoglycaemia
Hypoglycaemia is determined by a capillary blood glucose measurement of <4.0mmol/l. The following may point to a hypoglycaemic episode and prompt confirmation by CBG measurement is required:
Autonomic symptoms – pallor, sweating, tremor, tachycardia
Neuroglycopaenic symptoms – loss of concentration, behavioural changes, fits, transient neurological deficits, reduced level of consciousness
Some patients especially with long standing Type 1 diabetes may lose their awareness of hypoglycaemia and report no or very few symptoms despite having a “hypo”
Symptoms may be less easy to recognise in the elderly
If the CBG is <4.0mmol/l DO NOT delay initiation of treatment. Severe hypoglycaemia (CBG<3.0mmol/l) may result in severe patient harm or death if treatment delayed.
Potential Causes of Inpatient Hypoglycaemia
Medical reasons:
inappropriately timed diabetes medication for meal / enteral feed
insulin error, eg, wrong insulin, wrong dose, etc
use of IV insulin infusion without glucose infusion
inappropriate use of “stat” / “prn” quick acting insulin
discontinuation of long term steroid therapy / reducing steroid doses
recovery from acute illness / stress
change in activity levels, eg, mobilisation after illness
Reduced carbohydrate intake during inpatient stay:
missed or delayed meals
less carbohydrate in meals / smaller meals
change of the time of the biggest meal of the day
lack of access to usual between meals/snacks particularly bed-time snacks
prolonged starvation time eg, NBM, vomiting, reduced appetite
unplanned discontinuation of artificial nutrition following administration of insulin
Management of Hypoglycaemia
Hypoglycaemia must be treated promptly to prevent further deterioration, harm or death.
Where possible do all you can to reduce the risk of hypoglycaemia occurring, eg, reduce insulin doses where appropriate, ensure access to snacks at bedtime, etc.
For guidance on the management of inpatient hypoglycaemia see algorithm and links below:
Management of hypoglycaemic episode whilst on VRIII and treatment of hypoglycaemic episodes for patients with enteral feeds are covered in the relevant chapters.
What to do once hypoglycaemia has been successfully treated and CBG >4.0mmol/l?
Document hypoglycaemic episode in patient’s notes and ensure treatment and CBG readings recorded on the diabetes monitoring chart
If recurrent episodes (3 episodes or more), severe hypo (requiring iv or im rescue treatment) or loss of hypo awareness refer to the Diabetes Specialist nurses.
DO NOT OMIT SUBSQUENT DOSES OF INSULIN following treatment of hypos as this results in swings in CBG levels which can be difficult to manage. However if no obvious cause for hypo identified (eg, missed meal) subsequent doses may need reducing by 10 or 20% depending on severity of hypo to ensure further hypos do not occur (see Insulin dose titration decision support tool). CBG should be monitored 4 x day for next 48hrs while in hospital.
ITS ANIMATION: HYPOGLYCAEMIA