48 Monte Carlo Crescent Kyalami Business Park Kyalami, Johannesburg, 1684, RSA Tel: +27 (0)11 463 3260 Fax: + 27 (0)86 557 2232 Email: [email protected] www.thistle.co.za The HPCSA and the Med Tech Society have confirmed that this clinical case study, plus your routine review of your EQA reports from Thistle QA, should be documented as a “Journal Club” activity. This means that you must record those attending for CEU purposes. Thistle will not issue a certificate to cover these activities, nor send out “correct” answers to the CEU questions at the end of this case study. The Thistle QA CEU No is: MTS 18/062 Each attendee should claim ONE CEU point for completing this Quality Control Journal Club exercise, and retain a copy of the relevant Thistle QA Participation Certificate as proof of registration on a Thistle QA EQA. CHEMISTRY LEGEND September 2018 Hypoglycemia Hypoglycemia, also known as low blood sugar, is when blood sugar decreases to below normal levels. Normal blood sugar levels are Between 4.0 to 5.4 mmol/L (72 to 99 mg/dL) when fasting. Up to 7.8 mmol/L (140 mg/dL) 2 hours after eating. The glucose level that defines hypoglycemia is variable. In people with diabetes, levels below 3.9 mmol/L (70 mg/dL) is diagnostic. In adults without diabetes, levels below 2.8 mmol/L (50 mg/dL) after not eating or following exercise may be used. In newborns, a level below 2.2 mmol/L (40 mg/dL), or less than 3.3 mmol/L (60 mg/dL) if symptoms are present, indicates hypoglycemia. Signs and symptoms There is no consistent order to the appearance of the symptoms, if symptoms even occur. Specific manifestations may also vary by age, by severity of the hypoglycemia and the speed of the decline. In young children, vomiting can sometimes accompany morning hypoglycemia with ketosis. In older children and adults, moderately severe hypoglycemia can resemble mania, mental illness, drug intoxication, or drunkenness. In the elderly, hypoglycemia can produce focal stroke-like effects or a hard-to-define malaise. The symptoms of a single person may be similar from episode to episode, but are not necessarily so and may be influenced by the speed at which glucose levels are dropping, as well as previous incidents Other symptoms of hypoglycemia may include: Shakiness, anxiety, nervousness Palpitations, tachycardia Sweating, feeling of warmth (sympathetic muscarinic rather than adrenergic) Pallor, coldness, clamminess Dilated pupils (mydriasis) Page 1 of 4 48 Monte Carlo Crescent Kyalami Business Park Kyalami, Johannesburg, 1684, RSA Tel: +27 (0)11 463 3260 Fax: + 27 (0)86 557 2232 Email: [email protected] www.thistle.co.za Hunger, borborygmus Nausea, vomiting, abdominal discomfort Headache Causes Hypoglycemia is either reactive or non-reactive. Each type has different causes: a. Reactive hypoglycemia Reactive hypoglycemia occurs within a few hours after a meal. An overproduction of insulin causes reactive hypoglycemia. Having reactive hypoglycemia may mean that you’re at risk for developing diabetes. b. Non-reactive hypoglycemia Non-reactive hypoglycemia isn't necessarily related to meals and may be due to an underlying disease. Causes of non-reactive, or fasting, hypoglycemia can include: some medications, like those used in adults and children with kidney failure excess amounts of alcohol, which can stop your liver from producing glucose any disorder that affects the liver, heart, or kidneys some eating disorders, such as anorexia pregnancy Diagnosis If you use insulin or another diabetes medication known to lower blood sugar, and you have signs and symptoms of hypoglycemia, test your blood sugar levels with a blood glucose meter. If the result shows low blood sugar (under 70 mg/dL), treat accordingly. If you don’t have diabetes but suspect you have hypoglycemia, talk to your doctor about your symptoms. They will perform a physical examination. They will use three criteria, sometimes referred to as “Whipple’s triad,” to diagnose low blood sugar. These include: Signs and symptoms of low blood sugar: Your doctor may ask you to take a fasting test. This test can last as long as 72 hours. During the test, you’ll have your blood drawn at different times to measure your blood glucose level. The results are usually available within a day or two. If your Page 2 of 4 48 Monte Carlo Crescent Kyalami Business Park Kyalami, Johannesburg, 1684, RSA Tel: +27 (0)11 463 3260 Fax: + 27 (0)86 557 2232 Email: [email protected] www.thistle.co.za blood sugar level is lower than 50 to 70 milligrams per deciliter, you may have hypoglycemia. That number can vary from one person to another. Some people's bodies naturally have lower blood sugar levels. Your doctor will diagnose you based on your blood sugar levels. Documentation of low blood sugar when your signs and symptoms occur: Your doctor will perfom a blood test to analyze your blood sugar levels in a laboratory. Disappearance of the signs and symptoms of low blood sugar: Your doctor will want to know whether the signs and symptoms go away when your blood sugar levels are raised. Another test is a mixed-meal tolerance test. This test is for people experiencing hypoglycemia after eating and helps measure how much insulin your pancreas can make in response to food. Prevention The most effective means of preventing further episodes of hypoglycemia depends on the cause. The risk of further episodes of diabetic hypoglycemia can often (but not always) be reduced by lowering the dose of insulin or other medications, or by more meticulous attention to blood sugar balance during unusual hours, higher levels of exercise, or decreasing alcohol intake. Episodes of hypoglycemia can also be resolved by Simple changes to your diet and eating schedule which can also prevent future episodes. Treatment Treatment of some forms of hypoglycemia, such as in diabetes, involves immediately raising the blood sugar to normal through the ingestion of carbohydrates, determining the cause, and taking measures to hopefully prevent future episodes. Blood glucose can be raised to normal within minutes by taking (or receiving) 10–20 grams of carbohydrate. It can be taken as food or drink if the person is conscious and able to swallow. If a person is suffering such severe effects of hypoglycemia that they cannot (due to combativeness) or should not (due to seizures or unconsciousness) be given anything by mouth, medical personnel such as paramedics, or in-hospital personnel can establish IV access and give intravenous dextrose, concentrations varying depending on age (infants are given 2 ml/kg dextrose 10%, children are given dextrose 25%, and adults are given dextrose 50%). Care must be taken in giving these solutions because they can cause skin necrosis if the IV is infiltrated, sclerosis of veins, and many other fluid and electrolyte disturbances if administered incorrectly. If IV access cannot be established, the patient can be given 1 to 2 milligrams of glucagon in an intramuscular injection. Page 3 of 4 48 Monte Carlo Crescent Kyalami Business Park Kyalami, Johannesburg, 1684, RSA Tel: +27 (0)11 463 3260 Fax: + 27 (0)86 557 2232 Email: [email protected] www.thistle.co.za References 1. https://en.wikipedia.org/wiki/Hypoglycemia. 2. https://www.healthline.com/health/hypoglycemia-without-diabetes 3. https://www.diabetes.co.uk/diabetes_care/blood-sugar-level-ranges.html Questions 1. Define the term Hypoglycemia. 2. Discuss the diagnosis of Hypoglycemia. 3. How can Hypoglycemia be treated? Page 4 of 4 .