Hypoglycemia Case Study
Cassandra Reynolds
Cheshire Medical
Center/Dartmouth-Hitchcock/Keene
 Cheshire Medical
Center/Dartmouth-Hitchcock
Keene is a non-profit community
hospital and clinic who—through
their clinical and service excellence,
collaboration, and compassion for
every patient, every time—have a
mission to lead the community to
become the nation's healthiest
 65 average daily census
 Founded the Healthy Monadnock
2020 initiative
Dietitians at Cheshire
 Can work with all medical conditions at Cheshire Medical
Center/Dartmouth-Hitchcock/Keene
 Each patient is screened using a malnutrition screening tool
and assessed by an RD if at nutritional risk
 Rounding: ICU, medsurg, rehab bedside rounding
 Nutrition consults
Patient J
 84 year old male
 Presented at ER on March 15th after a fall
 Head CT negative
 Found to have UTI, antibiotics given and sent home
 March 16th- early AM at home
 Pt found by daughter: flailing in bed, unable to get up, slurred
speech
 EMS arrived, found pt’s blood glucose to be in the 40’s
Medical history:
 A fib, congestive heart failure, cardiomyopathy, COPD, MI,
recent surgery to remove a growth on the ribs (ischemic fasciitis
fibroelastoma), recent falls, UTI
 Recovering alcoholic, 2 years sober
Would drink 6 beers and 2 brandies/day
 History of smoking
Patient not diagnosed with diabetes: A1C of 5.7
Anthropometrics
 Unintentional weight loss
 Weight March 2014: 187 #
 Weight November 2014: 177#
 Weight February 2015: 162 #
 Upon Admission: 157 #
16% wt loss in 1 year
 Height: 6’ 2”
 BMI: 21.9
Patient history
 Lives alone at home, wife widowed
 Doesn’t like to cook
 Sometimes eats only 1 meal/day
 Eats frozen meals and daughter brings prepared food for pt
 Reports experiencing spells for 4-6 weeks characterized by cold
sweats, racing heart, and hunger. Symptoms will improve when
he eats.
Initial Plan
 Hypoglycemia work up:
 Labs: Beta Hydroxybutyrate, C-Peptide, Insulin Level, Urine
Sulfonylurea
 Assess regular diet
 Repeat Head CT
 Assess blood glucose regularly
 Consult Endocrinology
 C-Peptide is a breakdown
product of insulin
Normal: .05-2.0
nanograms/mL
 Proinsulin is a building block
of insulin
 Normal: 2-6 pmol/L
 Beta Hydroxybutyrate is a blood ketone
 Normal <.28 mmol/L
 Urine Sulfonylurea
 Can be useful to assess is hypoglycemia is resulting from exposure
to sulfonylurea hypoglycemic drugs (drugs that help the pancreas
produce more insulin: glyburide, glipizide)
Day 2: Endocrinology Consult
CT Scan of abdomen and pelvis negative for mass or
adenopathy (swollen lymph nodes)
Differential causes for hypoglycemia
 Malnutrition
 Endogenous hyperinsulinemia
Recommended plan by Endocrinology
 Check serum cortisol level given recent prednisone
use for COPD
 Cortisol and insulin resistance
 ↑Steroids= ↓ ACTH= ↑ Cortisol= ↑Glucose
production= ↑Insulin resistance = …. ↑blood glucose
 Evaluate for malnutrition
 albumin, pre-albumin, nutrition consult
 Evaluate for insulinoma
 Measurement of C-peptide, insulin, proinsulin and
serum glucose finger stick when BG <50 and
hypoglycemic symptoms present
Malnutrition evaluation
 Albumin can be useful to detect malnutrition but can also be
influenced by dehydration, liver disease, infection, nephritic
syndrome, post-op, edema and over hydration
 Pre-albumin shorter half life: can be influenced by chronic
renal failure, acute catabolic states, post surgery, liver disease,
infection and dialysis
**Cannot diagnose with only these labs
Day 2 Nutrition Consult
 Requested by MD to assess what patient is eating at home
 Diet recall revealed 1600-1800 daily kcal intake
 Some swallowing difficulty with pills: swallowing evaluation
requested
 Patient feels he has lost weight in the last 2 years because he
quit drinking beer
Patient needs
 Calories: 1927 (REE x 1.3, using miflin equation)
 Protein: 72 grams (1 gram/kg)
Nutrition related lab values
 Albumin: 2.8 g/dL (low)
 Calcium: 8.5 mg/dL (low)
 Potassium: 3.2 mmol/L (low)
 Creatinine: 0.7 mg/dL (low)
PES Statement
P:
 Inadequate energy and protein intake
 Swallowing difficulty (modified barium swallow requested)
 Altered nutrition related lab values
 Underweight
 Involuntary weight loss
E: Inadequate PO intake of kcals to prevent weight loss
S: Muscle mass loss, unintentional weight loss, subcutaneous fat
loss
My PES
 Altered nutrition related lab values (r/t) malnutrition or
insulinoma (aeb) frequent hypoglycemic episodes
Intervention
 Patient diagnosed with “non-severe malnutrition”
 Plan:
 Begin sending HS Ensure
 Calorie counts initiated
 Calorie counts found pt to be eating 2500-3000 kcals/day
while inpatient
 Patient states he’s eating more here than at home
 Continues to decline in weight
Glucose while in hospital
 Patient continued to experience very low blood sugars
 ranging anywhere from 30-70 mg/dL. Usually between 12 AM
and 7 AM
 Normal blood sugars during the day
 100-165 mg/dL on average
 Night shift neglected to draw blood prior to treatment of
hypoglycemia
Day 5 Nutrition follow up
 Patients weight showed an 10# increase from yesterday.156.6# on 3/19 to
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166.7# on 3/20.
Spoke with the patient to see if he felt he was retaining fluid and he stated he
did not, no obvious signs of edema noted
Question of weight accuracy.
Patient has switched from thick liquids to regular and he feels he is doing ok
with that switch.
Has been drinking both of the ensures sent to him.
States he has been eating really well. Will d/c calorie counts.
Will continue to monitor weight.
Blood glucose levels are more steady, only dipping to 82 throughout the night.
F/U on glucose monitoring.
Continue Regular diet, Ensure HS and once with breakfast
Day 6
 Awaiting insulinoma work up
 Hospitalist medical chart documentation:
“Non-Severe malnutrition with associated weight loss [as] likely
cause of hypoglycemia with decreased protein and decreased
albumin”
• Protein: 4.8 g/dL (normal 6.6-8.7)
• Albumin: 2.3 g/dL (normal 3.5-5.2)
Most recent low BS: 54 mg/dL on 3/21 at 0426
•
Ensure at bedtime but 0200 BS’s still low, Ensure ordered
for 0200
Day 6 Nutrition Follow up
 Eating well. Pt weight increased up from 166# to 171#
 3/21 glucose: 54 at 0426, 3/23: glucose: 106 at 04:51.
 2 AM snack initiated this morning.
 Per MD, patients lab work has all been reviewed and the
issue with hypoglycemia is attributed to his decreased
nutrition PTA.
 Discussed with patient the need for HS and 2 AM Ensure
supplements, he is not able to say he will do this after discharge.
Need to speak with patient's family about need for
snacks/supplements.
Day 7
 Patient experiencing hallucinations
Insulinoma labs reviewed **** Blood drawn when BS >50
 C-peptide: 2.43 ng/mL (normal)
 Insulin: 4.1 mmol/L (normal)
 Cortisol: 13.77 nmol/L (normal)
 Beta-hydroxybutyrate 0.08 mmol/L(normal)
Day 8 Endocrinologist F/U
“Thus far there has been no documented serum glucose <55
and therefore haven’t evaluated for endogenous insulin
production. However, since point of care glucose currently 61
we will send insulin, pro-insulin, C-peptide and serum glucose
now. Certainly if insulin levels are high in the setting of
relatively low serum glucose we will have reason to more
aggressively pursue this diagnosis.”
 Test results: C-Peptide and B-hydroxybutyrate high, insulin
normal
Day 9
 Hospitalist medical chart documentation
“Repeat tests done but serum glucose level was not low so the
value may be nil. Etiology still unclear and therefore a
management plan that doesn’t include close monitoring may be
difficult to envision.”
Day 9 Nutrition follow up
 Patients blood sugar continues to drop in the early morning, this
morning going down to 55 at 0600. He was given 4 pieces of
toast, orange juice and ensure which brought his blood sugar up to
71 at 0645.
 Asked his nurse if he has been drinking the 0200 Ensure but that
was unknown.
 Patient ate 100% of dinner on 3/24 and >50% of HS snack:
ensure and ice cream.
 Will continue to f/u on 0200 Ensure. Currently he is being sent 3
Ensure supplements, one at 10 AM one at HS and another at 0200.
Day 10
 Hospitalist medical chart documentation
 “Serum glucose level this AM was 44 but no insulin
workup sent by RN responsible for him.”
 “I think that if we fail to obtain a dx for the
hypoglycemia we will need an effective means of
managing it before he could be sent home safely”
Day 11
 Endocrinologist suggests Diazoxide every 8 hours.
 Will be available in 3 days (Monday)
 Resend Insulin, Pro-Insulin, C-Peptide, and B-
Hyrdoxybutyrate
Diazoxide
 Originally invented as a non-diuretic hypotensive agent
 Found to have a hypoglycemic effect
 “Diazoxide is primarily indicated for the treatment of severe
hypertension (particularly when associated with renal
disease) and chronic intractable hypoglycemia
occurring, for instance, in the context of an
insulinoma.”
 Works by slowing insulin release from the pancreas
Day 11 Nutrition follow up
 3/27:Glucose:56-low
 Weight 166#, remaining fairly stable
 Patient was NPO this morning, has not eaten yet, appetite is
so, so.
 Patient reports he has been drinking the Ensures at HS but
maybe not at 2 AM. He is planned to start Diazoxide on
Monday for hypoglycemia. Hopefully this will help with early
morning hypoglycemia which is still a problem.
 Will continue with supplements, follow PO intake, weight,
labs and progress.
Day 13
 Medical Chart documentation:
 Suspect glycogen depletion as reason for hypoglycemia
 Plan: Long discussion for treatment of hypoglycemia
 Glucose tablets followed by CHO plus protein or milk
Day 15
 Medical Chart Documentation:
 Started Diazoxide yesterday at 1 pm
 Since then BS’s: 54 (this AM), 124, 81
 Continue meal plan of frequent snacks, ensure and “rescue” plan
Blood Sugars on Diazoxide
3/30
81
124
3/31
54
93
89
112 *Diazoxide
increased to
100 mg
4/1
93
108
134
97
Day 16 Endocrine follow up
 “Diagnosing endogenous hyperinsulinema has proven
difficult. Simultaneous C-Peptide, Insulin, Pro-insulin and BHydroxybutyrate finally sent yesterday when serum glucose
was 50 (7:50 AM 3/30).
 Results:
 C-Pep 2.05 ng/mL (elevated)
 Insulin 2.7 mmol/L (normal)
 Pro-insulin and B-hydroxybutyrate pending
Endocrine assessment/plan
 Given the patients overall frail health status and probable high
surgical risk, further imaging or invasive testing to evaluate
for insulinoma is probably not indicated
 Plan: Continue Diazoxide as needed and tolerated to
eliminate hypoglycemic events. Careful meal planning (and
hypoglycemia protocol) will be needed on discharge.
Day 18 Nutrition follow up
 Glucoses: 105, 159, 127, 95 ,115
 Meds include: Diazoxizide
 Discussed fasting hypoglycemia with patient.
 We discussed the need for high kcal foods in order for patient
to maintain weight. Patient is looking forward to his large
bowl of ice cream before bedtime at home.
 Phone number of RD office given to patient.
 Available for questions.
Day 22 Discharge
 Patient discharged to SNF on April 7th
 Discharge diagnosis
 Hypoglycemia with question of increased endogenous insulin
production
 Discharged on regular diet with small frequent meals, and to
watch blood sugar closely.
Discussion points…
 Do we agree with the diagnosis?
 Malnutrition severity?
 Insulinoma r/t growth on ribs?
 Weight changes:
 16.5 # range
Day 1:
157.5
Day 2:
160.9
Day 3:
157.6
Day 4:
156.6
Day 5:
**166.7
Day 6:
**171.3
Day 7:
174
Day 8:
173
Day 9:
174
Day 10:
**168
Day 11:
167
Day 12:
166
Day 13:
167
Day 14:
165
Day 15:
166
Day 16:
163.9
Day 17:
165.8
Day 18:
166.2
Day 19:
165.2
Day 20:
**170.8
Day 21:
170.3
Day 22:
173.3
Resources
 Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V.
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(2012). Krause's food & the nutrition care process (13th
ed.). St. Louis, Mo.: Elsevier/Saunders.
Academy of Nutrition and Dietetics. Nutrition Care
Manual. http://www.nutritioncaremanual.org. Accessed May,
2015
http://www.nlm.nih.gov/medlineplus/ency/article/000387.ht
m
http://www.uthsc.edu/endocrinology/documents/DM_Hypo/I
nsulinoma.pdf
Labtestsonline.org