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HHF – : ASSESSMENT & MANAGEMENT

CONSIDERATIONS: i. Have long standing 1. Hypoglycemia associated with diabetes mellitus is ii. Are using an intensive management seen in patients treated with insulin and insulin approach secretagogues (medications that work by causing iii. Are pregnant the to secrete more insulin, such as iv. Have autonomic neuropathy sulfonylureas). v. Use beta-blockers and have comorbidities 2. Hypoglycemia is not a disease; it is a condition These patients may need to be on a regular caused by an underlying problem/disease that schedule, e.g., every 3 or 4 hours prevents the body from maintaining normal blood 4. Symptoms of hypoglycemia include: levels. The ADA Consensus Workgroup defines hypoglycemia by type of event. a. Mild: Hypoglycemic events include: i. Sweating a. Severe hypoglycemia requires the assistance of ii. Tachycardia another person to administer carbohydrate, iii. Tremors, poor coordination glucagons, or other resuscitative actions. Due iv. Dizziness, lightheadedness to the mortality associated with this type of v. Difficulty concentrating, feeling of anxiety event, blood glucose levels may not be b. Severe: available during the event i. Confusion, inability to treat self b. Documented symptomatic hypoglycemia occurs ii. Seizures, loss of consciousness when typical hypoglycemic symptoms are 5. Treat hypoglycemic patients with 15 grams of fast- accompanied by documented blood glucose of acting sugar or carbohydrate if blood glucose level ≤70 mg/dl is: c. Asymptomatic hypoglycemia occurs when the a. 70 mg/dL or less patient does not experience the typical b. Between 70 – 100 mg/dL and the patient is hypoglycemia symptoms but the blood glucose experiencing symptoms of hypoglycemia level is documented to be ≤70 mg/dl 6. Sources of 15 grams of fast acting carbohydrate d. Probable symptomatic hypoglycemia occurs in include: patients who treat symptoms of hypoglycemia without testing blood glucose. It is presumed a. Unsweetened fruit juice, 4 oz. (Use apple juice the symptoms were caused by a blood glucose for patients with impaired renal function.) level ≤70 mg/dl b. Regular soda, 4 oz. (not diet soda) e. Relative hypoglycemia occurs when the patient c. Sugar water, 4 teaspoons sugar in 4 oz. water reports any of the typical hypoglycemic d. Glucose tablets, 4 tablets symptoms, interpreting them as hypoglycemia, e. Milk, 8 oz. (preferably non-fat or low fat) but with a documented blood glucose level >70 7. Symptoms of hypoglycemia in insulin-treated or oral mg/dl. This is seen in patients with chronically insulin secretagogues patients can occur poor glycemic control precipitously. Causes include: 3. Correlation between hypoglycemia symptoms and a. Medication error blood glucose levels vary among individuals with b. Omitting meal diabetes. However, because lower glucose levels c. Increase in activity impair defenses against subsequent hypoglycemia, Patient should be coached to have ready source of glucose levels lower than 70 mg/dL are defined as carbohydrate available at all times. hypoglycemia. Hypoglycemia episodes vary greatly 8. Patients taking insulin or oral insulin secretagogues in severity. But hypoglycemia severity is defined by to treat diabetes should be instructed in symptoms, not blood glucose values: a. Prevention of hypoglycemia a. Mild hypoglycemia or autonomic nervous system symptoms include: sweating, trembling, b. Recognizing signs/symptoms of hypoglycemia tachycardia, dizziness, difficulty concentrating, c. Treatment of hypoglycemia lightheadedness and poor coordination EQUIPMENT: b. Severe hypoglycemia or neuroglycopenia symptoms include: mental confusion, lethargy, Blood glucose testing equipment (See Endocrine inability to self-treat, seizures and loss of System - Blood Glucose Testing) consciousness PROCEDURE: c. Hypoglycemic unawareness occurs when a person does not feel or recognize the 1. If patient is unconscious or having seizures: symptoms of hypoglycemia. It occurs in patients a. Call 911 (emergency transport system) who:

Endocrine System – Hypolgycemia: Assessment & Management Page 1 of 3

HHF Endocrine System – HYPOGLYCEMIA: ASSESSMENT & MANAGEMENT

b. Administer Glucagon if prescribed/available d. Causes identified leading to hypoglycemia (See Endocrine System - Glucagon e. Confidence and commitment of patient/ Administration.) caregiver to regain glucose control c. Obtain blood glucose f. Instructions given to patient/caregiver 2. If patient has signs or symptoms of hypoglycemia, g. Communication and orders from physician perform a capillary blood glucose test. (See Blood 2. Instruct patient/caregiver on: Glucose Testing.) a. Signs, symptoms, treatment and prevention of 3. If blood glucose is either below 70 mg/dL or hypoglycemia between 70 – 100 with hypoglycemic symptoms: b. Change in care if ordered by the physician a. Give one of these 15- gram fast-acting 3. Communicate with physician about: carbohydrate items: a. Severe hypoglycemic events (each and every i. 4 oz of unsweetened fruit juice time they occur) ii. 4 oz of regular soda b. Three or more hypoglycemic events in a week iii. 8 oz of Milk (nonfat/low-fat preferred) iv. 4 teaspoons sugar in 4 oz. water REFERENCE: v. 4 glucose tablets American Association of Clinical Endocrinologist (2011). b. Retest capillary blood glucose in 15 minutes to Medial Guidelines for Clinical Practice for determine appropriate rise in blood glucose Developing a Diabetes Mellitus Comprehensive 4. If blood glucose shows continued hypoglycemia Care Pan. Retrieved May 18, 2012 from after 15 minutes (< 70 mg/dL): https://www.aace.com/files/dm-guidelines- a. Repeat 15 grams of rapidly absorbing sugars or ccp.pdf carbohydrates American Diabetes Association (2012). Standards of b. Continue repeating capillary blood glucose Medical Care in Diabetes—2012. Diabetes testing every 15 minutes until the blood sugar Care. Retrieved May 17, 2012 from returns to normal 70 mg/dl or higher http://care.diabetesjournals.org/content/35/Supp c. If repeated attempts do not raise blood sugar lement_1/S11.ful above 70, call health care provider or 911 American Diabetes Association (2012). Hypoglycemia. 5. Once blood glucose returns to normal: Retrieved May 18, 2012 from http://www.diabetes.org/living-with- a. Instruct the patient to eat a snack or next meal, diabetes/treatment-and-care/blood-glucose- which includes protein and complex control/hypoglycemia-low-blood.html carbohydrates American Diabetes Association (2005). Defining and b. Monitor blood glucose again in about 60 Reporting Hypoglycemia in Diabetes: A report minutes to see if additional treatment is from the American Diabetes Association necessary Workgroup on Hypoglycemia. Retrieved May c. If patients are elderly, monitor closely for 17, 2012 from another hypoglycemic event over next 24 hours http://care.diabetesjournals.org/content/28/5/12 d. Explore with patient/caregiver possible causes 45.full of the event. Assess the patient’s/caregiver’s Childs, B.P., Grother, J.M., & Greenleak, P.J. (2012). of: Strategies to Limit the Effect of Hypoglycemia i. Blood glucose testing and recording log on Diabetes Control: Identifying and Reducing ii. Activity/exercise, including increases and the Risks. Retrieved May 18, 2012 from decreases http://clinical.diabetesjournals.org/content/30/1/ iii. management, with 28.full attention to extra or over-dosing National Diabetes Information Clearing House (NDIC). iv. Meal planning and carbohydrate counting, Hypoglycemia. Retrieved May 18. 2012 from with attention to omitting, decreasing, or http://diabetes.niddk.nih.gov/dm/pubs/hypoglyc restricting carbohydrates emia/#treatment e. Assess blood glucose pattern/ trends signaling U.S. National Library of Medicine. Diabetes Low Blood hypoglycemia and possible unawareness Sugar - Self-care. Retrieved May 18, 2012 from http://www.nlm.nih.gov/medlineplus/ency/patien AFTER CARE: tinstructions/000085.htm 1. Document in patient's record: a. Signs or symptoms of hypoglycemia b. Blood glucose test results c. Treatment given and patient's response to the treatment Endocrine System – Hypolgycemia: Assessment & Management Page 2 of 3

HHF Endocrine System – HYPOGLYCEMIA: ASSESSMENT & MANAGEMENT

White, J.R. (2007). The Contribution of Medications to Hypoglycemia Unawareness. Retrieved May 18, 2012 from http://spectrum.diabetesjournals.org/content/20/ 2/77.full

Adopted VNAA: Approved Policy Committee 03/11/14

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