Dr.Mehnaz Ferdous
CONSULTANT
CRITICAL CARE
 H y p o g ly c e m i a o c c u r s wh e n a
p e r s o n ’s bl o o d g l u c o s e l e ve l
( B G L ) d r o p s t o a ve r y l ow l e ve l
( b e l ow 4 m m o l / L )
(Diabetes Australia 2024).
Medical issues:
 Strict glycemic control
 Previous history of severe hypos
 Long duration of type 1 DM
 Organ dysfunction : Severe hepatic dysfunction,
Heart failure, CKD
 Adrenal insufficiency
 Terminal illness
 Cognitive dysfunction/dementia
• Increased exercise (relative to usual)
• Weight loss programs
• Alcohol
• Increasing age
• Early pregnancy, breastfeeding
• Lack of or inadequate blood glucose monitoring
• Religious fasting
 INSULIN AND OHA ADMINISTRATION ISSUES
 CARBOHYDRATE INTAKE ISSUES
 ENTERAL/PARENTERAL FEEDING ISSUES
 Autonomic symptoms
 Pallor
 Neuroglycopenic
symptoms
 Sweating
 Dizziness
 Shaking
 Hunger
 Impaired attention and cognition
 Impaired/double vision
 Tingling of mouth/fingers
 Slurred speech
 Anxiety
 Disorientation and confusion
 Palpitations
 Inappropriate behaviour
 Coma
 Seizures
LIPODYSTROPHY : When people who have diabetes use the
same spot to inject insulin, they can develop fibrous and
hardened areas. Therefore, the insulin does not get
absorbed from that site, causing the patient to increase their
dose.
If the patient then administers that higher dose of insulin in a
non-affected area, they are at risk of a severe hypo, because
they are absorbing 100% of that insulin, as opposed to
injecting it into the affected areas of lipohypertrophy.
 Those with impaired renal function, including patients on HD, will
have an increased hypo risk. This is because people need less insulin
once they’re on dialysis. Furthermore, as the kidneys (or renal
function) deteriorate, they are unable to remove the byproducts of
these medicines.
 Individuals with chronic kidney disease, heart failure and/or
cardiovascular disease have a higher rate of severe hypos than those
without comorbidity.
 Is the patient conscious and cooperative?
 Is the patient on an insulin infusion?
 Is the patient nil by mouth or nil by tube?
 Is the patient receiving food orally or NGT?
 Recognize Hypoglycemia : Consume 15 Grams of Fast-
Acting Carbohydrates Wait 15 Minutes: Allow time for the
carbohydrates to raise your blood sugar.
 Recheck Blood Sugar Repeat if Necessary
 Follow up with a meal: Once your blood sugar is stable,
have a larger meal with complex carbohydrates to prevent
further lows.
Examples include:
 150 ml regular (non-diet) soft drink
 Three teaspoons of sugar or honey/ 1
TABLESPOON
 125 ml fruit juice
 Note: Chocolate is no longer recommended due
to its high fat content, which slows down the
absorption of carbohydrates.
 Contact the doctor urgently and if IV access is in situ, administer 30 ml 50%
glucose as a slow IV push.
 If no IV access, administer 1 mg glucagon IM.
 Commence or revise IV glucose infusion.
 Recheck BGLs in 15 minutes.
 If BGL remains < 4.0 mmol/L, repeat initial treatment. If BGL is > 4.0 mmol/L, follow
up with oral carbohydrate or IV glucose.
 Stop insulin infusion, continue glucose infusion and contact the doctor
urgently.
 If the patient is nil by mouth, administer 30 ml 50% glucose as a slow IV
push. If the patient is not nil by mouth, implement usual oral hypo
treatment.
 Recheck BGL in 15 minutes.
 If BGL < 4.0mmol/L, repeat initial treatment. If BGL > 4.0 mmol/L, revise
insulin infusion rate and concurrent glucose infusion.
 Recommence insulin infusion and glucose infusion at adjusted rate for 15
minutes after the hypoglycaemic event has resolved.
 Place the person on their side, ensuring their airway is clear.
 Administer 1 mg glucagon IM if available and trained to do so.
 state ‘diabetic emergency’.
 Stay with the person and monitor airway and cardiac status.
 Notify the treating doctor.
 If the patient regains consciousness, give 15 g of fast-acting carbohydrate.
 Recheck BGL and if < 4.0 mmol/L and safe to do so, give another 15 g of fast-acting
carbohydrate.
 Repeat BGL checks every 15 minutes until the ambulance arrives.
 Neurological Damage
 Loss of Consciousness
 Cardiovascular Complications
 Mortality
 1. Patient with Type 1 Diabetes:
 A 10-month-old boy, Sam, is brought to the ED with symptoms like vomiting,
diarrhea, and lethargy. His blood glucose level is 37 mg/dL (2.05 mmol/L),
indicating severe hypoglycemia.
 Sam is given an intravenous dextrose bolus, which raises his blood glucose level to
82 mg/dL (4.55 mmol/L).
 The patient is then placed on maintenance IV fluids of 5% dextrose in normal
saline.
 Despite the initial treatment, Sam remains sleepy and unresponsive, prompting
further evaluation.
https://www.rch.org.au/clinicalguide/guideline_index/Hypoglycaemia/
 Patient with Type 2 Diabetes:
 A 67-year-old woman is found sweaty and
unresponsive at home, and her blood glucose
level is 1.2 mmol/L.
 After receiving dextrose intravenously, she
regains consciousness and her blood glucose
level increases to 3.8 mmol/L.
 3. Patient with Underlying Medical Conditions:
 A 62-year-old male patient is admitted to the hospital
unconscious and unresponsive, with a blood glucose level
of 11 mg/dl.
 He is immediately given intravenous dextrose and
monitored closely, as his blood glucose levels continue to
decline.
 The patient regains consciousness after four hours of IV
dextrose resuscitation but remains lethargic and
disoriented for a prolonged period.
 4. Insulinoma:
 An 82-year-old woman experiences confusion and is found
to have a blood glucose level of 28 mg/dl.
 She is admitted to the hospital for further evaluation and is
found to have a pancreatic tumor, an insulinoma, which was
causing the hypoglycemia.
 A 55-year-old woman with type 1 diabetes experiences severe hypoglycemia
after initiating sacubitril/valsartan for heart failure.
 Her insulin dose is adjusted and she is monitored for recurrent episodes.
 6. Post-Operative Hypoglycemia:
 A 69-year-old female patient, on the second post-
operative day following a laparoscopic cholecystectomy,
experiences low blood glucose.
 She has a history of Type 1 Diabetes and is receiving
insulin for her elevated blood sugar.
 Nurses are instructed to monitor her for signs of
hypoglycemia, cluster symptoms, recognize
deteriorating status, check blood sugar, and administer
appropriate interventions.