Hypoglycaemia

Question 1

when do non- diabetics start developing symptoms

Answer 1

HGT< 3.6 mmol/L

Question 2

when should diabetics be concerned

Answer 2

when their self- monitored HGT< 3.9 mmol/L

Question 3

what is whipple’s triad used to define

Answer 3

hypoglycemia in non- diabetics

Question 4

whipple’s triad

Answer 4

• symptoms and/or signs of hypoglycemia
  -low serum glucose
  -resolution of symptoms/ signs after administration of glucose

Question 5

what is diabetics hypoglycemia

Answer 5

Abnormally low plasma glucose ,with/without symptoms, that will expose the
individual to harm

Question 6

causes of hypoglycemia in diabetics

Answer 6

*hypoglycaemic agents (sulphonylureas,insulin)
*missed meals or overnight fasting
*↑ glucose utilisation (exercise)
*↓ endogenous glucose production (alcohol ingestion)
*↑ insulin sensitivity (weight loss, ↑ exercise)
*↓ insulin clearance (renal failure)

Question 7

causes of hypoglycemia in non- diabetics

Answer 7

*Drugs (insulin,oral hypoglycaemics, quinine, chloroquine, β-blocker/Valproate/Salicylate Overdose)
*Alcohol abuse in combination with malnourishment
*Pituitary insufficiency
*Acute liver failure
*Addison’s disease,Adrenal crisis
*Myxoedema
*Tumors (Insulinoma , retroperitoneal sarcoma)
*Starvation and malnutrition
*Infection (Severe sepsis, Malaria)
*Anxiety disorders
*Cardiogenic shock
*Pseudohypoglycaemia (delayed measurement of a sample in the presence of leukocytosis,
thrombocyosis or erythrocytosis)

Question 8

history taking in diabetic

Answer 8

current treatment regime?
any treatments changed?
extra meds administered?
missed meals?
exercise regime change?
recent illnesses (eg. CVA,Renal dysfunction) ?

Question 9

history taking in a non- diabetic

Answer 9

recent overdose of medication?
alcohol intake?
recent illnesses?

Question 10

symptoms of hypoglycemia

Answer 10

hunger
sweating
pounding heart
shaking
blurred vision
difficulty concentrating
anxiety
slurred speech
racing thoughts
tingling in the mouth
confusion
unreasonable hunger

Question 11

effects of hypoglycemia

Answer 11

*inflammation
- increased IL6
-increase VEGF
-increase CRP

*endothelial dysfunction
-decrease vasodilation

*sympathoadrenal response
-rhythm abnormalities
-hemodynamic changes
^^increase adrenaline- increase contractility
^^increase oxygen- increase workload

*blood coagulation abnormalities
-increase neutrophils activation
-increase platelet activation
-increase factor VII

Question 12

examination

Answer 12

Signs of sympathetic overactivity

Look for precipitants: liver failure,renal impairment,sepsis

Well controlled diabetics have more frequent hypoglycaemic episodes and
can become desensitized to sympathetic symptoms

β-blockers can blunt the sympathetic symptoms

Question 13

neuroglycopaenia

Answer 13

glucose < 2.6 mmol/L

Question 14

Signs of neuroglycopaenia (4 C’s)

Answer 14

Signs of neuroglycopaenia (4 C’s)

Question 15

investigations

Answer 15

1. Finger prick glucose and confirmed by lab glucose
2. Creatinine (U&E)
3. Further investigations are dictated by the suspected cause of hypoglycaemia.
4. Attempt to take blood samples prior to treatment in all non-diabetic patients
   for insulin and C-peptide levels.
   
   • A low C-peptide and high insulin level indicate exogenous insulin
   • A high C-peptide and insulin indicate endogenous insulin
     (eg. surreptitious drug [sulphonylurea] ingestion or insulinoma)

Question 16

management

Answer 16

-Based on severity
-Expect a rapid response to glucose within 10 minutes
-Repeat the finger prick glucose after 10 minutes
-Patient may develop permanent neurological complications if hypoglycaemic
> 4hours

Question 17

immediate action options

Answer 17

1. non drug treatment
2. drug treatment
3. hypoglycaemia not related to drugs or no cause found
4. hypoglycemia related to drugs, overdose, alcoholics

Question 18

non drug treatment

Answer 18

Stabilise ABCs,do blood gluse,O2 if hypoxic,IV access

Question 19

drug treatment

Answer 19

*Thiamine 1-2 mg/kg IV first alcoholic/ malnourished, to avoid Wernicke’s
^^Awake patient → 50g Dextrose or sugar water PO
^^If unconscious → 50ml 50% Dextrose IV
^^If no IV access → Glucagon 1mg IM then 50g Dextrose PO when awake

Question 20

hypoglycaemia not related to drugs or no cause found:

Answer 20

Start 5% Dextrose infusion 50-100ml/hr and do glucose 2hrly.
Refer to physician for work-up

Question 21

hypoglycaemia related to drugs, overdose, alcoholics:

Answer 21

-Patient must eat
-Perform glucose 2hourly
-↑ concentration of IV fluids if glucose drops again
-Look for co-existing causes
-Adjust diabetic meds if indicated
-Refer if recurrent hypoglycaemia or a 2° cause found

Question 22

referral criteria

Answer 22

• Diabetics with a clear,reversible cause for hypoglycaemia can be managed
  at your facility.
• All other hypoglycaemic patients need to be referred to a physician.

Question 23

discharge criteria

Answer 23

• Asymptomatic and off all infusions for at least 6hours,depending on cause.
• Cause identified and corrected
• Appropriate follow-up arranged