HYPOGLYCEMIA ALGORITHM

SOUTHERN PHILIPPINES MEDICAL CENTER

Department of Internal Medicine
Proposed by: Dr. Neil Carlo Ramos and Dr. Fatima Dhiena Julhan
Adviser: Dr. Suzette Alegarbes

Patient is:
Patient is:
• awake CBG < 80mg/dl • Unresponsive/Intubated
• responsive
• without risk of aspiration • With decrease in sensorium
• at risk of aspiration

Establish IV access:
PATIENT NOT ON NPO PATIENT ON NPO Give D50W as follows:
• 15cc IV for CBG <80 mg/dl
• 25cc IV for CBG <70 mg/dl
• 50cc IV for CBG <50 mg/dl
Give 15g of Glucose using:
Repeat CBG after 15mins
• 3 tsp of sugar + ½ glass water
• 150ml fruit juice or regular soda
• 1 tbsp of honey
Repeat CBG after 15mins

Is CBG now NO NO Is CBG now

> 100 mg/dl? > 100 mg/dl?

YES

YES
Instruct patient to take a
Repeat for 2 more takes with carbohydrate-containing Repeat for 2 more takes with
15-minute intervals snack or meal within 15-minute intervals
30minutes

PATIENT NOT ON NPO PATIENT ON NPO

Decrease CBG monitoring to

regular schedule

Resume feeding Maintain closer

monitoring of CBG
Evaluate Cause of every 4 hours
hypoglycemia and educate
patient for future prevention ONCE FEEDING IS RESUMED

SIGNS/SYMPTOMS OF HYPOGLYCEMIA WHAT NOT TO DO IN HYPOGLYCEMIA PREVENTION STRATEGIES

Adrenergic Symptoms Neuroglycopenic Signs • Recognizing precipitating factors

• Feed conscious patients milk or
• Pallor • Confusion • Ordering appropriate scheduled
chocolates (complex
• Diaphoresis • Slurred Speech insulin or anti-diabetic oral agents
carbohydrates)
• Tachycardia • Irrational Behavior • Monitoring blood glucose at
• Automatically give patients 2
• Shakiness • Disorientation bedside
• Syncope vials of D50W
• Hunger • Patient, family and staff education
• Avoid fruit juices for renal
• Anxiety • Seizures • Applying systems for eliminating or
patients
• Dizziness • Sluggish Pupils reducing medication and treatment
• Feed patients without checking
subsequent CBG errors

“HYPOGLYCEMIA NOT CORRECTED PROPERLY CAN BE AS JUST AS DEADLY HYPOGLYCEMIA ITSELF”

Tomky, D. (2005). Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum, 18(1), 39–44.
Hypoglycemia. (2013). Canadian Journal of Diabetes, 37, S314. https://doi.org/10.1016/j.jcjd.2013.02.013
 HYPOGLYCEMIA ALGORITHM
SOUTHERN PHILIPPINES MEDICAL CENTER
Department of Internal Medicine
Proposed by: Dr. Neil Carlo Ramos and Dr. Fatima Dhiena Julhan
Adviser: Dr. Suzette Alegarbes
HOW DO WE DEFINE HYPOGLYCEMIA?
• No universal value is recognized, but a CBG of less than or
equal to 80mg/dl can already be considered hypoglycemia.
WHAT ARE THE SIGNS & SYMPTOMS OF HYPOGLYCEMIA?
• Signs and Symptoms happen as a consequence of the
bodies compensatory response to decreasing blood sugar
levels. These vary and may occur at different severities of
hypoglycemia. These include:
• Pallor • Slurred Speech
• Diaphoresis • Irrational behavior
• Tachycardia • Extreme fatigue
• Shakiness • Disorientation
• Hunger • Loss of consciousness
• Anxiety • Seizures
• Irritability • Pupillary sluggishness
• Headache • Decrease response to
• Dizziness noxious stimuli
• Confusion
HOW DO WE PREVENT HYPOGLYCEMIA IN OUR PATIENTS?
• PATIENT EDUCATION – Patient involvement will promote
better compliance to medications and increase awareness
to the early signs and risk factors for hypoglycaemia.
Moreover, family and hospital staff education and
involvement can further aid in preventing hypoglycemia
• DIETARY INTERVENTION – Appropriate nutrition is
paramount for patients at risk of hypoglycaemia, even the
non-diabetic ones. A carbohydrate diet which matches a
patient’s insulin regimen is important. All meals should be
composed of carbohydrates should also be in balance with
protein, fat, and fiber.
• GLUCOSE MONITORING – Bedside monitoring of CBG
should be performed at least four times daily (before
meals and at bedtime for patients who are eating. Patient
who are on NPO or require continuous tube feeding should
have CBGs checked at least every 6 hours. In circumstances
of unusual tube-feeding schedule, timing of CBG
monitoring should also be coincided with the timing of
feedings
• MEDICATION ADJUSTMENT – Prompt and strict
adjustments of Insulin regimen, and knowing when to use
and discontinue OHAs should be
• RECOGNIZING TRIGGERING EVENTS – These include delays
in timing of meals or dosages of OHAs or insulin.
Comorbidities such as renal, adrenal, and pituitary
insufficiencies can also increase the risk of hypoglycaemia.
Knowledge of these risk factors should heighten awareness
of staff and the patient himself/herself to be more
stringent in the precautions to prevent hypoglycaemia.
Tomky, D. (2005). Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum, 18(1), 39–44.
Hypoglycemia. (2013). Canadian Journal of Diabetes, 37, S314. https://doi.org/10.1016/j.jcjd.2013.02.013
WHAT IS THE RATIONALE OF PROPER CORRECTION
OF HYPOGLYCEMIA?
• Current protocols employed are based on the
recommendation of correcting hypoglycaemia slowly
but correctly with 15-20 grams with a monosaccharide
such as glucose, and then rechecking for an increase in
the CBG after 15 minutes.
• This rate of correction allows for effective correction,
without the risk of overcorrection of hypoglycaemia,
which might lead to complications such as rebound
hyperglycemia, hyperosmolar syndrome, hypokalemia.
WHAT ARE THE COMMON MISTAKES IN CORRECTING
HYPOGLYCEMIA?
• FEEDING THE PATIENT MILK/CHOCOLATES – These are
complex carbohydrates which still take time to be broken
down into the simple sugars which are better absorbed by
the gastrointestinal tract. Use of these products lead to a
delay in correction of hypoglycaemia, and will also lead to
a later increase in the blood sugar levels once they are
fully broken down. A common reflex reaction to inpatients
are allowing them to be fed or to drink milk, especially
with patients on NGT feeding. These should be corrected
• KNEE-JERK REACTION TO GIVE FULL VIALS OF D50W – As
mentioned, correction of hypoglycaemia should depend
on the noted CBG levels, indicating a specific volume of
D50W per CBG level. This is to avoid overcorrection. Also,
in patients who are awake and able to feed, an oral route
of administering carbohydrates is still the more effective
way of treating hypoglycaemia.
• LACK OF GOOD CBG FOLLOW-UP AFTER CORRECTION –
Even though D50W or feeding has been started in a
hypoglycemic patient. Monitoring response after 15
minutes should not be neglected as not all immediate
feeding/D50W supplementation elicit an adequate
increase in CBG trends, and as such, complications may
still occur.
WE RECOMMEND EACH NURSE STATION TO HAVE IN STORE A
“HYPOGLYCEMIA PACK” FOR IMMEDIATE MANAGEMENT OF
ACUTELY HYPOGLYCEMIC PATIENTS, COMPOSING OF THE
FOLLOWING:
• White sugar packets x 9pcs • CBG strips x 10 pcs
• Bottled water 250ml x 3pcs • CBG monitor
• Regular Soda x 3 small cans • IV cannulas x 3pcs
• Honey 1 tbsp packets x 3 pcs • Macroset x 3pcs
• D50W 50cc vials x 3 pcs • Alcohol swab
• Disposable cups x 3pcs • Plaster