HYPOGLYCEMIA

HYPOGLYCEMIA

dr putra Hendra SpPD

UNIBA
 DEFINITION
DEFINITION

• Hypoglycemia or low blood glucose is a

clinical state associated with < 50mg/dl or
low plasma glucose with typical symptoms.
• Whipples triad =
• venous plasma glucose <50mg/dl.
• Classical symptoms.
• Relief of symptoms with glucose.
 Physiologic Responses to Hypoglycemia
Peripheral
Decreased sensors
CNS
glucose
(PNS)
Increased sympathoadrenal outflow
Beta
Cell
Decreased (SNS)
Adrenal
insulin medulla Increased NEIncreased ACh
Alpha (palpitations, (sweating, hunger)
Cell
tremor, arousal)

Pancreas
Decreased Increased Increased Increased
insulin glucagon epinephrine neurogenic symptoms

Liver
Increased glycogenolysis
+
Increased gluconeogenesis Muscle
Kidney Fat
Increased
lactate,
Increased amino acids, Decreased Increased
glucose production glycerol glucose clearance ingestion of carbohydrates
Increased
ACh=acetylcholine; CNS=central nervous system; NE=norepinephrine; PNS=parasympathetic nervous system; SNS=sympathetic nervous system. Reproduced with
glucose
permission of American Society for Clinical Investigation, from Cryer PE. J Clin Invest. 2006:116(6):1470–1473; permission conveyed through Copyright Clearance Center,
Inc.
 Common
Commonsymptoms
symptoms
Autonomic Neuroglycopenic General
Adrenergic
Sweating confusion nausea
Palpitation drowsiness headache
Tremor speech problems
Hunger incoordination
atypical behaviour
diplopia
Hypoglycemia
Symptoms,signs and hypoglycemic coma hyperglycemic
coma
laboratory findings
Laboratory tests
urine glucose -ve to +ve depending +ve

on time of last voiding

plasma glucose -ve to +ve +ve greater
than 200mg/dl
plasma acetone -ve usually present
plasma bicarbonate normal low less than
20mg/litre
plasma CO2 normal diminished
blood pH normal less than 7.35
 DD
DDofofhypoglycemic
hypoglycemicand
andhyperglycemic
hyperglycemiccoma
coma
Symptoms,signs and hypoglycemic coma hyperglycemic coma
laboratory findings
Physical findings
pulse rate increased increased
pulse volume full weak
temperature may be decreased may be decreased
respiration shallow or normal rapid and deep
blood pressure normal,may be increased decreased
skin clammy,sweating dry
Tongue moist dry
tissue turgor normal reduced
eyeball tension normal reduced
breath no acetone acetone may be
present
reflex brisk reflexes diminished reflexes
 S/Sx Hypo- Hyperglycemia
Hypoglycemia
• Shakiness, trembling
• Sweating (diaphoresis)
• Blurred vision
• Dizziness (feeling lightheaded)
• Cognitive impairment
• Feeling nervous or anxious
• Weakness
• Numbness, tingling of
   mouth and lips
• Tired
• Headache
• Sudden hunger
• Nauseous
• Rapid heart beat (tachycardia)
Hyperglycemia
• Increased thirst (polydipsia)
• Increase in urination (polyuria)
• Urine may contain ketones
• Labored breathing
• Fatigue
• Increase in appetite (polyphagia),
or decrease in appetite
• Headache, stomachache
• General aches and pain
• Changes in behavior or
temperament
 Risk
Riskfactors
factorsfor
forsevere
severehypo
hypo
• Intensive insulin therapy & tight glycemic control.
• Hypoglycemia unawareness –acute & chronic.
• Long duration of diabetes.
• Increasing age.
• Sleep.
• Excessive alcohol.
• Renal failure/ Hepatic failure
• Hypothyroidism/ Hypopituitarism/ Hypoadrenalism
 Complications and Effects of
Severe Hypoglycemia
Plasma glucose level

110
6

100

5 90

80
Increased Risk of Cardiac Progressive
4
70 Arrhythmia1 Neuroglycopenia2
60  Abnormal prolonged  Cognitive impairment
3
50
cardiac repolarization—  Unusual behavior
↑ QTc and QT dispersion  Seizure
40
2
 Sudden death  Coma
30

 Brain death
1 20
mmol/L

10
mg/dL

1. Landstedt-Hallin L et al. J Intern Med. 1999;246:299–307.

2. Cryer PE. J Clin Invest. 2007;117(4):868–870.
 MANAGEMENT
MANAGEMENTALGORITHM
ALGORITHM

Patient conscious Patient unconscious

Oral glucose/sucrose IV glucose (50%)
IM/SC glucagon

Recovery No recovery
I.V glucose (5%)

Follow up
-Identify cause
-Re-educate
Hypoglycaemic
Hypoglycaemicmortality
mortality
Causes
Causes
• Severe brain damage
• Hypostatic pneumonia
• Acute vascular events
• “Dead in Bed” Cardiac
arrhythmia
 Consequences of Severe Hypoglycemia
• Brain death1
• ECG changes that have been associated with2
– Ventricular arrhythmias
– Sudden death
• Nonfatal cardiac sequlae such as myocardial infarction 3
• Stroke3
• Motor vehicle and other accidents3
• Autonomic failure leading to unrecognized
hypoglycemia4
• Employment limitations3