Introduction
Hypoglycemia is defined as a glucose level of below 3.9 mmol/L. It is more common in people with type 1 diabetes, Cystic Fibrosis- associated diabetes and pancreatectomy-induced diabetes (type 3 diabetes).
Hypoglycaemic events can be dangerous and present atypically, so watch for the clues and manage the insulin regimen to avoid them.
Clinical presentation
Usually, patients don’t volunteer that they’re having hypoglycaemic events, so you need to have a high index of suspicion and look for clues that suggest they are having hypoglycemic events:
Typical symptoms of hypoglycaemia:
Atypical presentations are more common in elderly patients:
Causes of hypoglycemia
Insulin is the commonest cause of hypoglycaemia:
Other non-insulin causes:
Nocturnal hypoglycemia is more dangerous than those that occur in the day because the usual sympathetic response is delayed at night.
Therefore, nocturnal hypoglycemia events are likely to be:
Management of hypoglycemia
Immediate management involves:
Action | Patient can cooperate and swallow | Patient is unable to cooperate or swallow safely | Patient is unconscious or having seizures | |
Step 1 | Assess your patient’s level of consciousness and ability to swallow | |||
Step 2 | Immediate treatment | Give a dose of short acting carbohydrate* |
Give Glucagon 1 mg IMI stat. If Glucagon is unavailable, give a dose of glucose in the front of their mouth |
Give Glucagon 1 mg IMI stat. If Glucagon is unavailable, give a dose of glucose in the front of their mouth |
Step 3 | Check the glucose level | Check glucose |
Check glucose And consider calling the ambulance |
Call the ambulance Check glucose |
Step 4 | Recheck the glucose level | In 15 minutes | In 5 minutes | In 5 minutes |
Step 5: Option 1 | Glucose level is still below 4 mmol/L | Give another dose of short acting glucose | Give another dose of short acting glucose or Glucagon IMI 1mg | Give another dose of Glucagon IMI 1mg |
Step 5: Option 2 | Glucose level is above 4 mmol/L | Give 15 grams of long acting carbohydrate | If awake and following commands, give 15 grams of long acting carbohydrate | If awake and following commands, give 15 grams of long acting carbohydrate |
Step 6 | Post-hypoglycaemia care |
Look for causes of the hypoglycaemic event Adjust insulin doses to prevent further hypos If hypo was severe, aim for glucose targets 5 – 10 mmol/L |
Fast acting carbohydrate options (15 gram serves) |
Slow-acting carbohydrate (15 gram serves) |
|
Patient is able to self-care | Patient is unable to cooperate or swallow | Able to cooperate |
Choose one of the following: 4 Dextrose tablets Lucozade (100ml) Glucose gel (15g) Soft drink (full sugar) 150ml Juice 150ml 4 glucose jelly beans 7 regular jelly beans |
Gently introduce gel in the along the gums or over the tongue: Lucozade (100ml) Glucose gel (15g) Honey or jam (3 teaspoons) |
1 tub yoghurt 1 slice of bread Medium piece of fruit 1 glass of milk 1 muesli bar |
Follow-up after a hypoglycemic event
After a significant hypoglycemic event, close follow-up is required to:
If the cause for the hypoglycaemia is unclear, the following investigations are recommended:
Hypoglycemic unawareness
Hypoglycemic unawareness describes the situation where patients do not get the usual warning signs of hypoglycaemia until the glucose levels are very low. Glucose levels can be as low as 2 mmol/L before patients sense the hypoglycaemia and treat it.
This is very dangerous and occurs in patients:
It takes 6 weeks of normal glucose levels to recover hypoglycaemic awareness, so it is important to understand the causes and rationalize diabetes treatment to improve glucose control for that period. During that recovery period, aim for glucose levels between 5 and 10 mmol/L. Glucose targets can return to normal once hypoglycaemic events are avoided and hypo awareness has recovered.
Rules for driving
Preventing Hypoglycemia
Preventing the hypoglycaemia will depend on the cause of the hypoglycaemic events and the time that they typically occur (See Adjusting insulin to improve glycaemic control, Hypoglycemia).
For more information on managing diabetes during exercise and alcohol, direct your patient to the Patient information Lifestyle section.