Postoperative Management of Hypoglycemia Christine R. Wallace Individuals with Type 1 and Type 2 diabetes who are be presented. Critical self-management practices will be managed with insulin are at risk for developing described. hypoglycemia, a signifi cant consequence of insulin therapy. Traditionally hypoglycemia has been associated with Symptoms of hypoglycemia develop rapidly and the Type 1 diabetes. However, it has become a major con- condition can be life threatening. It is imperative that the cern in the management of Type 2 diabetes as an inpatient team, including the orthopaedic nurse, is able to increasing number of individuals with Type 2 diabetes are being prescribed insulin to manage their glucose recognize the signs and symptoms, respond appropriately, level and glucose targets have been tightened (Campbell and prevent hypoglycemia. It is equally important to provide & Braithwaite, 2004 ). The clinical practice recommen- the patient with education to prevent, identify, and self- dations from the American Diabetes Association (ADA, manage hypoglycemia at home. A case study example is 2012 ) recommend a glycemic goal for many nonpreg- included that addresses an elderly patient with Type 2 nant adults as a hemoglobin A1C no higher than 7% diabetes who had a total hip arthroplasty and developed equivalent to an estimated average glucose of 154 mg/dl. hypoglycemia postoperatively while on an orthopaedic unit. However, a less-intense hemoglobin A1C goal such as less Assessment, treatment, prevention, and patient self- than 8% may be appropriate for individuals with a his- management education of hypoglycemia are reviewed. tory of severe hypoglycemia (ADA, 2012 ). The recent intensifi cation of glycemic control and attainment of lower blood glucose level is associated with a signifi - r. D is a 75-year-old man admitted via am- cantly increased risk of developing hypoglycemia bulance to the emergency department after (Pearson, 2008 ). a fall on the ice, leaving the grocery store. A The most dangerous side effect of diabetes treatment witness attempted to ask Mr. D whether he is hypoglycemia (Plodkowski & Edelman, 2001 ). It is Mneeded assistance; however, Mr. D was confused. The becoming increasingly clear that the frequency of hypo- witness immediately called 911. When emergency medi- glycemic events in individuals with Type 2 diabetes has cal services arrived, Mr. D was unable to be aroused. Per been underestimated, partly because of limited symp- ambulance report, Mr. D’s blood glucose level was tom recognition in the elderly population (Fisher, 2010 ). 30 mg/dl on the scene and he received 1 amp of D50 Approximately 90% of individuals with diabetes who re- intravenous en route. His medical history includes a ceive insulin have experienced a hypoglycemic episode 15-year history of Type 2 diabetes mellitus complicated (Briscoe & Davis, 2006 ). Predictors for hypoglycemia in by peripheral neuropathy, hypertension, hyperlipid- a person with Type 2 diabetes are treatment with insu- emia, and renal insuffi ciency. When Mr. D arouses, he lin, a history of previous hypoglycemia, and duration of complains of severe pain in his left hip and an x-ray insulin treatment. Application of the ADA’s evidence- reveals an unstable left hip fracture. based clinical practice recommendations to the care of In addition to the medical history, the nursing assess- the patient with diabetes enables the orthopaedic nurses ment reveals that Mr. D experiences two episodes of hy- to provide high-quality care. poglycemia per week with symptoms of lightheaded- ness and difficulty concentrating. He admits to Presentation of Hypoglycemia hypoglycemia unawareness. The last time his insulin regimen was adjusted was 2 years ago. His social history Mr. D undergoes a left total hip arthroplasty and arrives indicates that he is widowed and lives alone. His daugh- on the orthopaedic unit postoperatively. It is postoperative ter lives 10 minutes away and they see each other twice a week when he visits his daughter’s home to eat dinner Christine R. Wallace, MSN, RN, PCCN-CMC, Advanced Practice Nurse, with his son-in-law and three grandchildren. The focus University Hospitals Seidman Cancer Center, Cleveland, Ohio . of this article is hypoglycemia in a postoperative The author has disclosed that she has no fi nancial interests to any orthopaedic patient with Type 2 diabetes. Treatment commercial company related to this educational activity. protocols and hypoglycemia-prevention strategies will DOI: 10.1097/NOR.0b013e31827424df 328 Orthopaedic Nursing • November/December 2012 • Volume 31 • Number 6 © 2012 by National Association of Orthopaedic Nurses Copyright © 2012 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. NNOR200343.inddOR200343.indd 332828 110/29/120/29/12 77:37:37 PPMM subcutaneously per his supplemental dose (insulin or- TABLE 1. SIGNS AND SYMPTOMS OF HYPOGLYCEMIA dered to correct high blood glucose), in addition to four Neurogenic (ANS) Neuroglycopenic units of lispro for his prandial dose (insulin ordered to be (Early Response to Falling (Brain Neuronal Glucose given at meal time). Before Mr. D fi nishes his breakfast, Glucose Levels) Deprivation) transport arrives and whisks him off to physical therapy Shakiness Abnormal mentation without notifying you. A short time later, physical therapy Anxiety Irritability calls the unit and tells you that Mr. D is sweaty and anx- Nervousness Confusion ious. You suspect a hypoglycemic episode and rush to the Palpitations Diffi culty speaking physical therapy department. Upon your arrival, you as- sess that Mr. D is pale, diaphoretic, and confused. You ob- Sweating Ataxia tain a capillary blood glucose level, which is 42 mg/dl. See Dry mouth Paresthesias Table 1 for the signs and symptoms of hypoglycemia and Pallor Headache Figure 1 for the physiologica l response to hypoglycemia. Pupil dilation Stupor Increased heart rate Seizures Increased systolic blood pressure Coma Physiological Response to Hunger Death (if untreated) Hypoglycemia Diaphoresis Let us fi rst examine the cause of Mr. D’s signs and symptoms. The brain depends on a continual supply of Note . ANS ϭ autonomic nervous system. “Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and glucose and is vulnerable to glucose deprivation. Management,” by V. J. Briscoe and S. N. Davis, 2006, Clinical Because of its inability to synthesize or store its main Diabetes, 24 (3), pp. 115–121. source of energy, the brain is one of the fi rst organs to be affected by lower blood glucose levels. Once the plasma day 2 and Mr. D is progressing as expected. His capillary glucose level falls below the physiological threshold of blood glucose level at 8 a.m. is 210 mg/dl. When Mr. D’s approximately 70 mg/dl, sequences of counterregula- breakfast arrives, you administer four units of lispro tory responses are activated (Briscoe & Davis, 2006 ). F IGURE 1. Critical elements for physiological response to hypoglycemia. © 2012 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2012 • Volume 31 • Number 6 329 Copyright © 2012 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. NNOR200343.inddOR200343.indd 332929 110/29/120/29/12 77:37:37 PPMM Different counterregulatory mechanisms are activated your hospital’s hypoglycemia protocol. Mr. D is lethar- at certain threshold levels of blood glucose. gic and at risk for aspiration; therefore, the hospital’s The key normal counterregulatory response is protocol requires you to administer 0.5 amp of D50, no- decreased endogenous insulin secretion, followed by an tify the physician, and document the event. When you increased secretion of glucagon and epinephrine. Both recheck his blood glucose 15 minutes later, it is 90 mg/dl hormones increase blood glucose levels mostly by and he is alert. Your success in responding to Mr. D’s activating glucose from the liver. In people with diabetes hypoglycemia depends on how well you know your who take insulin, all three counterregulatory mechanisms hospital’s protocol. The following is a review of the im- become compromised and eventually nonfunctional over portance of an evidence-based hypoglycemia protocol time (Pearson, 2008 ). The level of glucose that produces and the ADA’s 2012 clinical practice recommendations signs and symptoms differs greatly among individuals for treating hypoglycemia. and differs from one episode to another (Tkacs, 2002 ). For example, people with poorly controlled diabetes are likely to experience hypoglycemia symptoms at higher Treatment Using a Hypoglycemia blood glucose levels because their body is accustomed to Protocol higher blood glucose levels. In contrast, people under An evidence-based hypoglycemia protocol is a well- tight control of their blood glucose level are more likely recognized approach in providing high-quality patient to experience symptoms at a lower blood glucose level care. The hypoglycemia protocol includes evidence (Pearson, 2008 ). In Mr. D’s case, his diabetes is well con- on treatment and monitoring of hypoglycemia. trolled, and his laboratory results revealed that his hemo- Knowledge and adherence to the hypoglycemia proto- globin A1C was 7% upon admission. col are imperative to avoid recurrent hypoglycemia or hyperglycemia The ADA’s (2012) evidence-based clini- cal practice recommendations for hypoglycemia man- Signs and Symptoms of agement should be adopted and implemented