Management of Hypoglycemia in Hospitalized Patients

Hypoglycemia is defined as a blood glucose level of less than 70 mg/dL (3.9 mmol/L). It is the most common and most feared complication of insulin therapy in hospitalized patients. Severe hypoglycemia (blood glucose <40 mg/dL) can lead to seizures, coma, and death.

While stringent glycemic control has benefits, the risk of hypoglycemia often outweighs potential advantages. Hypoglycemia has been linked to poor clinical outcomes including higher mortality, longer hospital stays, and greater disability after discharge. Prevention and prompt treatment are essential.

Risk Factors

Certain patients are at greater risk for hypoglycemia in the hospital:

• Elderly patients – Impaired counterregulatory responses
• Patients with tight glycemic targets – Intensive insulin therapy
• Renal or hepatic dysfunction – Altered insulin metabolism
• Congestive heart failure – Sensitivity to sympathoadrenal response
• Severe insulin deficiency – Type 1 diabetes, low BMIs
• Hypoglycemia unawareness – Autonomic failure
• Intercurrent illnesses – Infection, myocardial ischemia
• Longer duration of diabetes – Beta cell failure
• High-risk medications – Insulin, sulfonylureas

Screening and Diagnosis

Clinical suspicion for hypoglycemia should be high in at-risk patients. Symptoms include sweating, tremors, palpitations, hunger, and neuroglycopenic signs like altered mental status, seizure, or loss of consciousness.

Frequent blood glucose monitoring is key for early detection. Point-of-care glucose meters should be available on all nursing units. Critical care units should have regular or continuous glucose data to identify hypoglycemic patterns.

Management of Mild Hypoglycemia (Glucose <70 mg/dL)

• Check glucose level with POC meter to confirm hypoglycemia.
• Administer 15-20 grams of simple carbohydrates:
• 4 glucose tablets
• 4 ounces of fruit juice
• 6 ounces of soda
• 1 tablespoon of honey, sugar, or corn syrup
• Recheck glucose in 15 minutes – repeat simple carbs if still <70 mg/dL.
• When glucose 70-100 mg/dL, provide complex carbs and protein (e.g. crackers and cheese).
• Identify and address the probable cause of hypoglycemia.
• Adjust medications if needed to prevent recurrence of hypoglycemia.

Management of Severe Hypoglycemia (Glucose <40 mg/dL)

• Obtain IV access immediately. Give 25 mL 50% dextrose injection (12.5 g dextrose).
• Position patient on side to prevent aspiration.
• Thiamine 100 mg IV should precede glucose if malnourishment or alcoholism concern.
• Recheck glucose after 5 minutes – give additional 12.5 g dextrose if still hypoglycemic.
• When glucose 70-100 mg/dL, provide complex carbs and protein.
• Notify physician for persistent hypoglycemia requiring >25 g dextrose.
• Identify and address the probable cause. Make medication adjustments.

Special Populations

Certain patients require modified approaches:

• Pregnancy – Goal is to maintain glucose >60 mg/dL.
• Malnourished patients – Give dextrose cautiously to avoid refeeding syndrome.
• Following bariatric surgery – Sip 15-30 g oral carbohydrates over 15 minutes.

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Prevention of Hypoglycemia

Preventing hypoglycemia is essential through:

• Careful selection of glycemic targets and drug regimens.
• Frequent blood glucose monitoring and attention to patterns.
• Adjustment of insulin for reduced oral intake or enteral feeds.
• Individualized diabetes education on hypoglycemia awareness.
• Coordination of carbohydrate intake and insulin administration.
• Verification of correct insulin doses by two nurses.
• Investigation of prior hypoglycemic episodes.
• Review of new medications that may increase hypoglycemia risk.
• Enlisting help from endocrinologists for complex insulin regimens.

Systems Approach

A systems-based approach can enhance hypoglycemia prevention:

• Standardized insulin order sets with management algorithms.
• Restriction of high-risk insulins like prandial or sliding scale.
• Alert systems for glucose values meeting critical thresholds.
• Point-of-care glucose meter downloading to identify patterns.
• Staff education on glycemic management and medication safety.
• Multidisciplinary root cause analysis of severe hypoglycemic events.

Inpatient to Outpatient Transition

Patients are especially vulnerable to hypoglycemia when transitioning from the highly monitored inpatient setting to less supervised outpatient management. Steps to reduce this risk include:

• Providing patients/caregivers with glucose monitoring supplies, fast-acting carbohydrates, and emergency glucagon kits.
• Scheduling close follow-up to reevaluate glycemic regimens.
• Communicating recent hypoglycemia to outpatient providers.
• Assessing ability to safely manage an intensive insulin regimen.
• Considering temporary de-escalation to basal insulin at discharge.

In summary, hypoglycemia remains a major threat during hospitalization despite improvements in glycemic management strategies. Clinical pharmacists play a critical role through therapeutic monitoring, high-risk medication review, staff education, and care transitions. A comprehensive approach can reduce the risks of this dangerous complication.