Hypoglycaemia

Question 1

For inpatients with diabetes, what blood-glucose concentration is considered hypoglycaemia that requires treatment?

Answer 1

Less than 4 mmol/litre

Question 2

Which two diabetes drugs most commonly cause hypoglycaemia?

Answer 2

Insulin

Sulfonylureas

Question 3

What must be excluded in any patient with diabetes who presents acutely unwell, drowsy, unconscious, unable to co-operate or with aggressive behaviour or seizures?

Answer 3

Hypoglycaemia

Question 4

What are the three options to treat hypoglycaemia in a diabetic?

Answer 4

1. Oral fast-acting carbohydrate (glucose is preferred)

OR if hypoglycaemia unresponsive OR oral route cannot be used

2. Glucagon IM injection (1 mg/mL)

OR if hypoglycaemia prolonged OR unresponsive to glucagon after 10 minutes

3. Glucose 10% IV infusion (adults + children)
   - Child: 5 mL/kg (glucose 500mg/kg)
   - Adult: 150-200 mL infused over 15 minutes

OR Glucose 20% infusion (adults)
- Adult: 75-100 mL infused over 15 minutes

Question 5

What is the first-line treatment for adults with symptoms of hypoglycaemia who have a blood-glucose concentration greater than 4 mmol/L?

Answer 5

A small carbohydrate snack (e.g. slice of bread)

OR

A normal meal (if due)

Question 6

What should be used to treat a patient with a blood-glucose concentration less than 4 mol/L, who is conscious and able to swallow?

Answer 6

Fast-acting carbohydrate by mouth

• Glucose liquid (Lift, Glucojuice)
• Glucose tablets
• Glucose 40% gels (Glucogel, Dextrogel, Rapilose)
• Pure fruit juice
• Sugar (sucrose) dissolved in an appropriate volume of water

Question 7

Why should you treat patients with hypoglycaemia (blood-glucose concentration < 4 mmol/L) with chocolate and biscuits?

Answer 7

Lower sugar content and high fat content may delay stomach emptying

Question 8

How many times can you repeat giving hypoglycaemia (blood glucose < 4 mmol/L) patient who can swallow fast-acting carbohydrates by mouth?

Answer 8

3 treatments in total

10-15 minutes apart

Question 9

A patient with hypoglycaemia (blood glucose < 4 mmol/L) has been given fast-acting carbohydrate by mouth but the blood-glucose concentration remains less than 4 mmol/L. What do you do next?

Answer 9

Repeat treatment (fast-acting carbohydrate by mouth) after 10-15 minutes

Up to a maximum of 3 treatments in total

Question 10

When treating hypoglycaemia (blood-glucose < 4mmol/L) with fast-acting carbohydrate by mouth, how many minutes do you wait before repeating the dose (if blood glucose remains < 4 mmol/L)?

Answer 10

10-15 minutes

Up to a maximum of 3 treatments in total

Question 11

Once a patient who have hypoglycaemia (blood-glucose < 4 mmol/L) has recovered and their blood-glucose concentration is above 4 mmol/L, what is the next step?

Answer 11

Provide a snack with a long-acting carbohydrate to prevent blood glucose from falling again

• Two biscuits
• One slice of bread
• 200-300 mL of milk (NOT alternative forms of milk)

Insulin should NOT be omitted if due, but the dose regimen may need review

Question 12

A patient with diabetes recently had an episode of hypoglycaemia, should they omit an insulin dose that is due?

Answer 12

NO

Insulin should NOT be omitted if due, but the dose regimen may need review

Question 13

If a patient with hypoglycaemia (blood glucose < 4 mmol/L) does not respond to fast-acting carbohydrate by mouth (3 treatment cycles), what is the next step?

Answer 13

IM glucagon

OR

Glucose 10% IV infusion

Question 14

In alcoholic patients with hypoglycaemia, what should be given with IV glucose?

Answer 14

Thiamine supplementation

To minimise the risk of Wernicke’s encephalopathy

Question 15

In alcoholic patients with hypoglycaemia, which do you give first, glucose or thiamine?

Answer 15

Thiamine

The concern is that an excessive carbohydrate load will lead to the build up of toxic metabolites when the activity of these enzymes is reduced because of thiamine deficiency

Question 16

(?) is a polypeptide hormone produced by the alpha cells of the islet of Langerhans, which increases blood-glucose concentration by mobilising glycogen stored in the liver.

Answer 16

Glucagon

Question 17

Glucagon is a polypeptide hormone produced by the (?) cells of the islet of Langerhans, which increases blood-glucose concentration by mobilising glycogen stored in the liver.

Answer 17

alpha

Question 18

Glucagon is a polypeptide hormone produced by the alpha cells of the islet of (?), which increases blood-glucose concentration by mobilising glycogen stored in the liver.

Answer 18

Langerhans

Question 19

Glucagon is a polypeptide hormone produced by the alpha cells of the islet of Langerhans, which increases blood-glucose concentration by mobilising (?) stored in the liver.

Answer 19

glycogen

Question 20

Glucagon is a polypeptide hormone produced by the alpha cells of the islet of Langerhans, which increases blood-glucose concentration by mobilising glycogen stored in the (?).

Answer 20

liver

Question 21

Which patients can you NOT treat hypoglycaemia with glucagon? (5)

Answer 21

1. Fasted for a prolonged period
2. Adrenal insufficiency
3. Chronic hypoglycaemia
4. Alcohol-induced hypoglycaemia
5. Taking a sulfonylurea (glucagon may be less effective)

1-4: glucagon is ineffective in patients whose liver glycogen is depleted

Question 22

If a patient has a decreased level of consciousness caused by hypoglycaemia, what should be used for treatment by a family member or friend?

Answer 22

IM glucagon

Question 23

If a patient receiving IV insulin becomes hypoglycaemia and unconscious, what should you do?

Answer 23

1. STOP IV insulin
2. IM glucagon

(If no response after 10 minutes)
3. Glucose 10% IV or 20% IV

Question 24

Why do we not use glucose 50% IV infusion to treat hypoglycaemia?

Answer 24

Hypertonic - increases the risk of extravasation injury
AND
Viscous - difficult to administer

Question 25

What are three examples of long-acting carbohydrate that should be given as soon as possible once the hypoglycaemic patient has recovered and their blood-glucose concentration is above 4 mmol/L (if they did not receive glucagon)?

Answer 25

1. Two biscuits 2. One slice of bread 3. 200-300 mL of milk (NOT alternative milk)

Question 26

Why do hypoglycaemic patients treated with glucagon require a larger portion of long-acting carbohydrate once they have recovered and their blood glucose is more than 4 mmol/L?

Answer 26

To replenish glycogen stores e.g. four biscuits, two slices of bread, 400-600 mL of milk (NOT alternative milk)

Question 27

What are three examples of long-acting carbohydrate that should be given as soon as possible once the hypoglycaemic patient, who was treated with glucagon, has recovered and their blood-glucose concentration is above 4 mmol/L?

Answer 27

1. Four biscuits 2. Two slices of bread 3. 400-600 mL of milk (NOT alternative milk)

Question 28

What should be given to patients who have recovered from hypoglycaemia and now have a blood-glucose concentration above 4 mmol/L AND are nil by mouth?

Answer 28

Glucose 10% IV infusion

Question 29

If you stopped an IV infusion of insulin because the patient became hypoglycaemia, when should you re-start the IV insulin?

Answer 29

Blood glucose concentration is above 3.5 mmol/L (concurrent glucose 10% IV infusion should be considered) Once you stop the IV insulin you should be checking the blood-glucose concentration every 15 minutes

Question 30

How long may a hypoglycaemc episode persist for if it was caused by a sulfonylurea or long-acting insulin?

Answer 30

24-36 hours following the last dose Especially if there is concurrent renal impairment

Question 31

How long should you continue to monitor the blood-glucose concentration of a patient following a hypoglycaemia episode?

Answer 31

24-48 hours

Question 32

Dose equivalence: 1 unit of glucagon =

Answer 32

1 mg of glucagon

Question 33

What is the contra-indication for the use of glucagon?

Answer 33

Phaeochromocytoma

Question 34

What is a common side effect of glucagon?

Answer 34

Nausea Vomiting is uncommon

Question 35

IV infusion of glucagon should NOT be added to infusion fluids containing (?)

Answer 35

calcium Precipitation may occur

Question 36

Prolonged administration of glucose solutions without electrolytes can lead to (?) and other electrolyte disturbances

Answer 36

hyponatraemia Do NOT give alone except when there is no significant loss of electrolytes

Question 37

Why are IV injections containing more than 10% glucose not given to children?

Answer 37

Irritant Injections containing more than 10% glucose can be irritant and should generally be given into a central venous line.