Algorithm for the Management of Hypoglycaemia in Adults with Diabetes Mellitus in Hospital

Hypoglycaemia is defined as blood glucose of less than 4 mmol/L (if not less than 4 mmol/L but patient is symptomatic, give a small carbohydrate snack for symptom relief). Please note that the use of 50% glucose is not recommended - 10% solutions are preferred.

Mild Patient conscious, orientated and able to swallow.

Moderate Patient conscious but confused/disorientated or aggressive and able to swallow.

Severe Patient unconscious/fitting or very aggressive or nil by mouth (NBM)

Give 15g of quick acting carbohydrate of patients choice e.g. 1 dose of GlucoJuice or 4 GlucoTabs tablets or 4 heaped teaspoons of sugar dissolved in water. Test blood glucose level after 15 minutes. If still less than 4 mmol/L repeat up to 3 times. If this has been repeated 3 times, contact a doctor. Consider 10% glucose IV at 100 ml/hr or 1 mg Glucagon IM.

If capable and cooperative, treat as for mild hypoglycaemia. Test blood glucose level after 15 minutes. If not capable and cooperative but able to swallow give either 1 tubes of GlucoGel squeezed into mouth between teeth and gums, or contact a doctor and give 1mg glucagon IM. Test blood glucose level after 15 minutes. If still less than 4 mmol/L, repeat as above. Continue to test every 15 minutes and repeat up to 3 times if still less than 4 mmol/L. If this has been repeated 3 times, contact a doctor. Consider IV 10% glucose at 100 ml/hr.

Check ABC, stop any IV insulin, fast bleep a doctor. If patient suitable for IM glucagon (i.e. no repeated hypos, patient not starved/NBM and no severe hepatic disease) give 1 mg glucagon IM. If not, give 150 ml 10% glucose IV over 15 minutes. Repeat capillary blood glucose 10 minutes later. If still <4 mmol/L, repeat up to 3 times.

Blood glucose level should now be above 4 mmol/L. Give 15g of long acting carbohydrate of patients choice e.g. 2 biscuits or a slice of bread or next meal if due. If IM Glucagon has been used, give 30g of long acting carbohydrate in order to replenish glycogen stores. For enteral feeding patients ONLY Give 200 ml milk (not soya) or restart feed or give IV 10% glucose at 100 ml/hr.

Recheck glucose level after 10 minutes; it should now be above 4 mmol/L. Follow up treatment as described on the left.

If NBM give 10% glucose infusion at 100 ml/hr until no longer NBM or reviewed by doctor.

Document event in patients notes. Do not omit subsequent doses of insulin however, dose review may be required. Continue regular capillary blood glucose monitoring for 24 to 48hours and give hypoglycaemia education or refer to DSN.

For TPN fed patients, refer to a dietitian/nutrition team and diabetes team for individual assessment.
Reference: The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus (March 2010) NHS Diabetes. Available at:
http://www.diabetes.org.uk/Documents/About%20Us/Our%20views/Care%20recs/Joint%20British%20Diabetes%20Societies%20Inpatient%20Care%20Group%20%20The%20Hospital%20Management%20of%20Hypoglycaemia%20in%20Adults%20with%20Diabetes%20Mellitus.pdf

Safe Use of Insulin Group, September 2012