Hypoglycaemia in diabetics

E10.0/E11.0/E12.0/E13.0/E14.0

• Description
• Diagnosis
• Emergency treatment
• Referral

DESCRIPTION

Diabetic patients on therapy may experience hypoglycaemia for reasons such as intercurrent illness (e.g. diarrhoea); missed meals; inadvertent intramuscular injections of insulin or miscalculated doses of insulin or progressive renal failure leading to decreased insulin clearance; alcohol ingestion; and exercise without appropriate dietary preparation.
Risk factors include age <6 years of age, low HbA1c, and longer duration of diabetes.

Hypoglycaemia in diabetic patients can be graded according to the table below:

*Except children < 6 years of age.

*Note:

• Children, particularly < 6 years of age, generally are not capable of self- management and are reliant on supervision from an adult.
• Patients may fail to recognise that they are hypoglycaemic when neuroglycopenia (impaired thinking, mood changes, irritability, dizziness, tiredness) occurs before autonomic activation.

DIAGNOSIS

• Blood glucose < 4mmol/L with symptoms in a known diabetic patient.
• Blood glucose concentrations should be measured with a glucometer to confirm hypoglycaemia.

Hypoglycaemia must be managed as an emergency.
If a diabetic patient presents with an altered level of consciousness and a glucometer is not available, treat as hypoglycaemia.

EMERGENCY TREATMENT

• Measure blood glucose concentration with glucometer/testing strip, immediately.

Conscious patient, able to feed

Breastfeeding child

• give breast milk

Older children

• A formula feed of 5 mL/kg

OR

• oral sugar solution
  • dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water, administer 5 mL/kg

OR

• sweets, sugar, glucose by mouth

Adults

• sweets, sugar, glucose by mouth

OR

• oral sugar solution
  • dissolve 3 teaspoons of sugar (15 g) in 200 mL cup of water, administer 5 mL/kg

Conscious patient, not able to feed without danger of aspiration

Administer via nasogastric tube:

• Dextrose 10%, 5 mL/kg
  • Add 1 part 50% dextrose water to 4 parts water to make a 10% solution.

OR

• milk

OR

• sugar solution
  • Dissolve 3 teaspoons of sugar (15 g) in 200 mL of water, administer 5 mL/kg.

Unconscious patient

Children

• Dextrose 10%, IV, 2–5 mL/kg.

IV administration of dextrose in children with hypoglycaemia:

• Establish an IV line. Do not give excessive volumes of fluid: usually can keep line open with 2mL/kg/hour.
• Take a blood sample for emergency investigations and blood glucose.
• Check blood glucose.
  • If low, i.e. < 2.5 mmol/L or if testing strips are not available, administer 2–5 mL/kg of 10% dextrose solution IV rapidly.
    In the majority of cases an immediate clinical response can be expected.
• Re-check the blood glucose after infusion.
  • If still low, repeat 2 mL/kg of 10% dextrose solution.
• After recovery, maintain with 5–10% dextrose solution until blood glucose is stabilised.
• Feed the child as soon as conscious.

Adults

• Dextrose 10%, solution, IV, 2–5 mL/kg.
  • Do not give unless hypoglycaemic or hypoglycaemia strongly suspected.
  • Do not give excessive volumes of fluid.
  • If hypoglycaemia is treated:
    • re-check blood glucose 10–15 minutes later;
    • if still low, give a further bolus of dextrose 10%, IV, 2 mL/kg, and commence dextrose 5 or 10%, infusion, 3–5 mL/kg/hour to prevent blood glucose dropping again.

Assess continuously until the patient shows signs of recovery.

LoEIII [9]

Alcoholics (or where alcohol intake cannot be excluded)

• Thiamine, IV/IM, 100 mg immediately.

CAUTION

Thiamine should preferably be administered prior to intravenous glucose to prevent permanent neurological damage.
Do not delay the dextrose administration in a hypoglycaemic patient.

REFERRAL

Urgent

• All hypoglycaemic patients on oral hypoglycaemic agents.
• Hypoglycaemic patients who do not recover completely after treatment.
• All children with documented hypoglycaemia unless the cause is clearly identified and safe management instituted to prevent recurrence.