top of page

THE MORNING REPORT

The Best in FOAM Education

  • Jin Yao Li, DO

Hypoglycemia

Presentation

Autonomic Response:

  • Catecholaminergic/adrenergic mediated:

    • Nervousness/anxiety

    • tachycardia

    • palpitations

    • Tremors

  • Acetylcholinergic/cholinergic mediated:

    • diaphoresis

    • Hunger

    • Paresthesias

Neuroglycopenic symptoms:

  • Confusion

  • behavioral changes

  • dizzy/weakness

  • seizures

  • transient focal neurologic deficits

  • loss of consciousness

  • visual disturbances


How low is low?

  • Moderate 40-70mg/dL

  • Severe <40mg/dL


Differential diagnosis:

Medications

  • Insulin

  • sulfonylureas

  • Alcohol

  • Beta-blockers

  • Acetaminophen overdose

Systemic illness

  • Sepsis

  • myxedema coma

  • Myocardial infarction

  • hepatic disease

  • adrenal insufficiencies

Other

  • Lab error

  • Leukemia, erythrocytosis, hemolytic disease

  • post-surgical: Gastric bypass

  • Anorexia nervosa


Work-up

  • point-of-care / fingerstick glucose

    • can be artificially elevated by maltose (patients receiving IVIG or peritoneal dialysate)

    • may be inaccurate in patients with poor perfusion

  • chemistries

  • hepatic panel

  • TSH

  • Beta-hydroxybutyrate

  • EKG, Troponin when indicated

  • infectious work-up when indicated: CBC, CXR, UA, blood cultures

  • ethanol levels

  • Inpatient workup

    • insulin, C-peptide level, pro-insulin level, glucagon, growth hormone, cortisol, insulin antibodies


Management

IV dextrose bolus

  • D50W ampules

    • 1 ampule = 50mL of D50W = 25g glucose

    • Serum glucose concentrations increase approximately 4-6 mg/dL per gram of dextrose administered

      • serum glucose levels rise approximately 100-150mg/dL per ampule of D50W

    • This is short-lived. Approximately 30 minutes. MUST follow-up with PO carbohydrate dense foods if able to tolerate PO

  • D5W or D10W drips

    • Advantages: Less irritating to veins, lower risk of overshooting to hyperglycemia

    • Disadvantages: takes slightly longer to administer. Less useful in patients with profound hypoglycemia

  • Pediatrics

    • Rule of 50s

    • the concentration of dextrose multiplied by the dosage (cc/kg) equals 50


Age

Dextrose concentration

Dose

<1yo

D10

5 cc/kg

1-8yo

D25

2 cc/kg

>8yo

D50

1 cc/kg

Oral glucose

  • If patient is awake and able to tolerate PO, ALWAYS give PO. This is the most efficient way to provide carbohydrates with appropriately sustained glucose levels

  • 1L IV D5W contains 50g glucose. Typical infusion rates are 100cc/hr. This means that a patient will only get 5g glucose per hour!

Glucagon

  • MOA: releases endogenous glycogen storages

  • Dosage: IM/IV/SubQ 1mg may repeat in 15 minutes as needed

  • Note: may not be helpful in patients with deficient glycogen storages (hepatic diseases, chronic alcohol use)

Octreotide

  • Used for sulfonylurea induced hypoglycemia

  • MOA: Somatostatin analogue, reduces insulin secretion

  • Dosage:

    • IV/SubQ: 50-100mcg

    • May repeat every 6hrs

    • May use IV continuous infusion 50-125mcg/hr

Steroids

  • useful for adrenal insufficiency & insulin overdoses who require large amounts of dextrose infusions

  • Dosage: hydrocortisone IV: 50mg q6hrs or 100mg q8hrs


Disposition

  • May discharge after 4-6hrs of observation if:

    • glucose remains stable

    • patient able to tolerate PO

    • Symptomatically resolved

    • Etiology identified with unlikely recurrence

  • Admission if the above criteria are not met




Jin Yao Li, DO


References

  • Balentine JR, Gaeta TJ, Kessler D, Bagiella E, Lee T. Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers. Acad Emerg Med. 1998;5(7):691-694. doi:10.1111/j.1553-2712.1998.tb02487.x

  • Murthy MS, Duby JJ, Parker PL, Durbin-Johnson BP, Roach DM, Louie EL. Blood glucose response to rescue dextrose in hypoglycemic, critically ill patients receiving an insulin infusion. Ann Pharmacother. 2015;49(8):892-896. doi:10.1177/1060028015585574

  • Adler PM. Serum glucose changes after administration of 50% dextrose solution: pre- and in-hospital calculations. Am J Emerg Med. 1986;4(6):504-506. doi:10.1016/S0735-6757(86)80004-3

  • Farkas J. Hypoglycemia. EMCrit Project. Published April 1, 2023. https://emcrit.org/ibcc/hypoglycemia/

  • Donaldson R, Fadial T, Ostermayer D, et al. Hypoglycemia - WikEM. wikem.org. Published September 28, 2019. Accessed January 21, 2024. https://wikem.org/wiki/Hypoglycemia


Kommentare


bottom of page