TAM (Treatments and Medicines) NHS Highland
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Patient conscious, orientated and able to swallow and not fasting |
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Give 15 to 20g of quick acting carbohydrate, for example:
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| Recheck blood glucose level after 10 to 15 minutes. |
| If blood glucose still <4mmol/L and patient is able to swallow repeat treatment up to 3 times. |
| If blood glucose < 4mmol/L or deteriorating at any stage, call doctor and consider IV glucose (as for severe) or 1mg Glucagon IM (once only) |
Hypoglycaemia in hospital (Guidelines)
Warning
Audience
- Secondary care only
- Adults only
Hypoglycaemia in adults with diabetes mellitus in hospital: Diabetes thinkcheckact algorithm
Hypoglycaemia is a serious condition and should be treated as an emergency regardless of level of consciousness. Hypoglycaemia is defined as blood glucose of less than 4mmol/L in people treated with insulin therapy and hypoglycaemic agents such asgliclazide, glipizide, glimepiride. If blood glucose is not less than 4mmol/L, but the patient is symptomatic, give a small carbohydrate snack for symptom relief.
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Patient conscious and able to swallow, but confused, disorientated or aggressive |
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| If patient capable and co-operative; treat as for mild hypoglycaemia If patient is not capable and co-operative but can swallow; give 1.5 to 2 tubes of glucose gel, for example Glucoboost® (squeezed into mouth between teeth and gums). |
| Recheck blood glucose after 10 to 15 minutes. |
| If blood glucose still <4mmol/L; repeat above up to 3 times. If ineffective, use 1mg Glucagon IM (once only) |
| If blood glucose < 4mmol/L or deteriorating at any stage, call doctor and consider IV glucose. |
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Patient unconscious/fitting, very aggressive or nil by mouth (NBM) |
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Check ABC and contact doctor urgently Stop IV insulin (if infusing) Give IV glucose over 10 to 15 minutes as:
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| If blood glucose still < 4mmol/L after 10 minutes; repeat IV glucose. |
| If IV insulin has been switched off, restart infusion once blood glucose is > 4mmol/L and consider a reduced hourly rate of insulin. |
Give 20g of long acting carbohydrate, for example two biscuits / slice of bread / 200 to 300ml milk / or next meal (give 40g if IM Glucagon has been used). If NBM, once blood glucose > 4mmol/L, give 10% glucose infusion at 100ml/hour (less in patients with renal/cardiac disease) until no longer NBM or reviewed by doctor. Patients with enteral feeding tube. Give 20g quick acting carbohydrate via enteral tube, for example 50 to 70ml Ensure Plus® or 60ml Glucojuice®*, then flush. Check blood glucose after 10 to 15 minutes. Repeat treatment up to 3 times or use IV glucose if needed. If IV insulin has been switched off, restart when Blood glucose is > 4mmol/L with concurrent IV glucose. Review the indication and need for ongoing insulin management. Continue regular capillary blood glucose monitoring for 24 to 48 hours. Provide hypoglycaemia education or refer to the diabetes team. RESTOCK THE HYPO BOX
Hypoglycaemia – blood glucose level <4mmol/L
- A potentially dangerous side effect of insulin therapy and hypoglycaemic agents (sulfonylureas)
- Prompt treatment is required
Think
Common causes of hypoglycaemia
- Inadequate food intake, fasting, delayed or missed meals
- Too much insulin or hypoglycaemic agents
- Insulin administration/drug administration at an inappropriate time
- Problems with insulin injection technique/injection site causing variable insulin absorption
- Increased physical activity
- Alcohol
At risk groups
- Strict glycaemic control, impaired hypoglycaemic awareness, cognitive impairment, extremes of age, breastfeeding mother with diabetes
- Conditions that increase risk of hypoglycaemia
- Malabsorption, gastroparesis
- Abrupt discontinuation of corticosteroids, hypoadrenalism, renal or hepatic impairment, pancreatectomy
Check
Assess recent pattern of blood glucose levels i.e. last 48 hours.
- Establish when and what the patient last ate
- Check insulin/diabetes medication is being prescribed and administered at correct dose, time, and in relation to food intake
- Check for signs of lipohypertrophy (lumpy areas at injection sites) which may affect insulin absorption
- Check credibility of blood glucose monitoring, for example hand washing before testing
Act
- Treat hypoglycaemia in line with protocol
- Observe patient until recovery complete
- Establish the cause of hypoglycaemia and take action to prevent recurrence. Inform patient if medication dose is changed
- Do not omit insulin in type 1 diabetes - treat hypoglycaemia and administer insulin as usual after dose review
- Blood glucose is likely to be high following hypoglycaemia; additional correction doses should not be given
- If receiving IV insulin treatment, check blood glucose every 15 minutes until above 4.0mmol/L, then restart IV insulin after review of infusion rates and requirement for IV insulin
- Provide patient information on hypoglycaemia management
- Consult diabetes team for advice if necessary, and refer all patients with severe hypoglycaemia
- ABC: Airway, Breathing, and Circulation
- IM: intramuscular
- IV: intravenous
- NBM: nil by mouth