DIABETES AND HYPOGLYCEMIA
PRACTICE GUIDE
When using any Practice Guide, always follow the Guidelines of Proper Use
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Definition
● Defect in glucose regulation secondary to inadequate
secretion of insulin or resistance to insulin
Considerations
Types
● Type 1: dependent on exogenous insulin to live
● Type 2: does not need insulin to live (peripheral
insulin resistance and insulin-secretory defect)
● Type 2 can present initially as DKA (diabetic
ketoacidosis) in African-Americans or Hispanic
descent patients
● Gestational — appears with pregnancy only
Complications
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Increased infections
Peripheral arterial insufficiency
Skin ulcers and gangrene of lower legs and feet
Hyperglycemic and hypoglycemic emergencies
Pediatric cerebral edema with hyperglycemic
emergencies
Vascular
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Retinopathy
Renal insufficiency and failure
Coronary arteries occlusion
Aortic atherosclerosis
Stroke
DKA
(Notify physician promptly)
● Secondary to stress
● Infection most common
● AMI
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● Pregnancy
● Surgery
Average adult fluid deficit is 6–10 liters (osmotic
diuresis)
Plasma glucose > 250 mg/dL (usually > 350 mg/dL)
Adjustment to serum Na (sodium) levels — each
additional 100 mg% over plasma glucose of 100 add
1.6 mEq/L to serum Na levels
Potassium body deficit can be severe despite initial
normal serum level (a decrease of 0.3–0.7 mEq/L for
each decrease of pH of 0.1)
● Total body potassium deficit is 3–5 mEq/kg
IV PO4 (phosphorous) may be needed if respiratory
failure occurs
Arterial pH < 7.3 (with venous pH add 0.03 if used
instead of ABG)
Serum osmolarity > 320 mOsm/L
Serum bicarbonate < 18
Moderate ketonuria or ketonemia
Symptoms and findings (some or all)
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Weakness
Weight loss
Mental status changes
Dry mucous membranes
Tachycardia
Nausea and vomiting
Abdominal pain
Kussmaul respirations (deep rapid breathing)
Peripheral vasodilatation can cause normothermia
or hypothermia despite infection
Evaluation
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CBC
BMP
Accucheck
Chest x-ray
U/A
ABG or venous pH (add 0.03 to adjust to arterial
pH)
● Blood, urine or infected site cultures if infection
suspected
Serum osmolality
• If < 320mOsm/L, look for another cause of
altered mental status
• Osmolol gap > 10–20; suspect substance
ingestion (normal < 10)
 Gap = Osmolality measured – Osmolality
calculated (Osmolality calculation equation:
2(Na+K) + glucose/18 + BUN/2.8; normal
280–300mOsm/L)
 Ethanol mg%/4.6 is added to osmolol gap
equation if present
 Gap > 50 carries high specificity for toxic
alcohol such as methanol, ethylene glycol,
or isopropyl alcohol
 Normal gap < 10
Fluid therapy
Adult
• IV NS infused 15–20 cc/kg/hour (1–1.5 liters
average)
• Continue NS if corrected Na is low
• 0.45% NS at 4–14 cc/kg/hour after bolus
infusion if “corrected” Na is normal or high
• Add potassium 20–30 mEq/L when serum K
reaches < 5.3 mEq/L (if urine output 0.5–1
cc/kg/hour)
Pediatric (< 16 years of age)
• IV NS 10–20 cc/kg/hour; may repeat prn;
should not exceed 50 cc/kg total over 4 hours
• Continued IV with 0.45% or NS at 5
cc/kg/hour after initial fluid therapy
• If altered mental status acutely occurs,
suspect cerebral edema (treatment 1–2
gms/kg mannitol IV — per physician)
Insulin therapy
● Start after IV fluids given for one hour
● Check K+ level first (can cause K+ to drop; can
be dangerous if already low; should be at least
3.3 mEq/L)
Adults
• Bolus 0.15 units/kg IV and/or continuous
infusion 0.1 unit/kg/hour (up to 5–7
units/hour)
• Should decrease plasma glucose 50–75
mg%/hour (if not, check hydration status)
Pediatrics
• Insulin bolus not recommended
• Continuous infusion same as adult
Potassium
● Add potassium 20–40 mEq to each liter of IV
fluids when serum K+ < 5.3 mEq/L if urine output
0.5–1 cc/kg/hour or initial potassium < 3.3 mEq/L
• Serum K+ 4.5−5.2 mEq/L give 10 mEq/hour
IV
• Serum K+ 3.0−4.5 mEq/L give 20 mEq/hour
IV
• Serum K+ initially < 3.0 mEq/L hold off
starting insulin and give potassium IV per
physician
Consult criteria
● All DKA patients after initial assessment
Hyperglycemic Hyperosmolar Syndrome
(HHS)
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Develops over days or weeks
Plasma glucose > 600
Serum osmolality > 320 mOsm
Profound dehydration: adult 8–12 liters fluid deficit
Small amount of ketonuria; small or absent ketonemia
Serum bicarbonate > 15
Arterial pH > 7.3
Some alteration of consciousness
Higher mortality than DKA
Associated medications contributing to HHS
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Diuretics
Propranolol
Calcium channel blockers
Dilantin
Cimetadine
Corticosteroids
Evaluation
● Same as for DKA
Treatment options
● IV NS 10–20 cc/kg/hour; may repeat prn; should
not exceed 50 cc/kg total over 4 hours
● Continued IV with 0.45% or NS at 5 cc/kg/hour
after initial fluid therapy
● Add D51/2NS or D5NS when plasma glucose
reaches 300 mg/dL
● Start insulin infusion 0.1 unit/kg/hour (up to 5–7
units/hour) after first hour of IV fluid therapy
• Insulin doses often lower than used in DKA
Potassium treatment
• Add potassium 20–40 mEq to each liter of IV
fluids when serum K+ < 5.3 mEq/L if urine
output 0.5–1 cc/kg/hour or initial potassium
< 3.3 mEq/L
 Serum K+ 4.5−5.2 mEq/L give 10
mEq/hour IV
 Serum K+ 3.0−4.5 mEq/L give 20
mEq/hour IV
 Serum K+ initially < 3.0 mEq/L hold off
starting insulin and give potassium IV per
physician
Consult criteria
● All cases
Hypoglycemia
Differential diagnosis
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CVA
TIA
Epilepsy
Multiple sclerosis
Psychosis
Considerations
Caused by:
• Accidental or intentional overdose of diabetic
medications
• Sepsis
• Alcohol use
• Decreased caloric intake
Symptoms
• Severity symptoms depends on glucose level
and rate of glucose decline
• Symptoms may be masked by betablockers
• Altered and decrease mental status
• Sweating
• Shaking
• Anxiety
Evaluation
● History and physical exam
● Medication and food intake history
● Accucheck every 30 minutes  2 hours or longer
until stable glucose levels achieved
● BMP
● CBC if infection suspected
● Chest x-ray if pneumonia or aspiration suspected,
or hypoxic
● U/A if infection suspected
Treatment options
● Awake and alert: complex calorie intake PO
● Altered mental status: IV D50W 1 amp adults
(100 calories)
● D25W ― 1 gm/kg in pediatrics not to exceed adult
dose
● D12.5W for neonates (1 gm/kg)
● D10W drip at 75–100 cc/hour (adult) if repeat
D50W boluses needed for recurrent hypoglycemia
or hypoglycemic agent overdose
● Glucagon 1 mg IM if no IV access
• May not work with depleted glycogen stores
in malnutrition
 Liver disease
 Alcoholics
 Neonates
● Octreotide can be used in sulfonylurea refractory
hypoglycemia (consult physician)
● Hydrocortisone IV for adrenal insufficiency
Discharge criteria
● Stable glucose levels in diabetic patients on
preexisting insulin therapy
● Good home support
● Reliable patient
Discharge instructions
• Hypoglycemia aftercare instructions
• Follow up with primary care provider within
12–24 hours
Consult criteria
● Oral hypoglycemia therapy (usually need
admission)
● Fasting hypoglycemia on no diabetic medication
● Intentional insulin overdose
● Poor home situation
● Abnormal vital signs
● Continued altered mental status
● Significant comorbidities (cancer, hepatic disease,
malnutrition, etc.)
Hyperglycemia without DKA or HHS
Considerations
● Most diabetic patients with elevated glucose levels
are asymptomatic
● High glucose levels can affect body water balance
● Acute treatment for levels up to 400 usually not
needed unless there is a concurrent disease
process
Evaluation
● Glucose < 400 without other disease processes or
symptoms may not need further testing acutely in
patient with history of poor control (if vital signs
normal and mentation changes or comorbidities
absent)
● Tests are directed to disease processes that may
be elevating glucose levels
● BMP
● CBC if infection or inflammatory process
suspected
● U/A if UTI suspected
Discharge criteria
● If new onset obese adult patient with DM without
DKA or HHS and glucose < 200
● Diabetic history with glucose < 400
● No metabolic acidosis
● No dehydration
● Normal vital signs and no mentation changes
Discharge instructions
• Hyperglycemia aftercare instructions
• Follow up with primary care provider within
1–5 days
• Return if patient develops symptoms
Consult criteria
New onset
• New adult onset DM with glucose > 300
• New onset pediatric DM with glucose > 200
mg/dL
Diabetic patient with
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Significant comorbid symptoms
Metabolic acidosis
Vomiting
Dehydration
Tachycardia
Hypotension
Relative hypotension SBP < 105 with history
of hypertension
Orthostatic vital sign changes
Progressive renal insufficiency creatinine
increase > 0.5
Adult heart rate ≥ 110
Pediatric heart rate
 12–15 years ≥ 115
 16 years or older ≥ 110
Glucose ≥ 400 in asymptomatic diabetic patient
Treatment for Type 2 Adult Diabetes If
Desired
Obese
Monotherapy
• Metformin 500 mg PO bid with or after meals
 1 week, increase weekly by 500 mg to
achieve 1000 mg PO bid
Second drug if needed
• Micronase 2.5 mg PO qd after breakfast
(elderly 1.25 mg PO)
Third drug if needed
• Avandia 4 mg PO qd
OR
• Actos 30 mg PO qd
Non-obese
Monotherapy
• Metformin 500 mg PO bid with or after meals
 1 week, increase weekly by 500 mg to
achieve 1000 mg PO bid
OR
• Micronase 2.5 mg PO qd after breakfast
(elderly 1.25 mg PO)
Second drug if needed
• Metformin 500 mg PO bid with or after meals
 1 week, increase weekly by 500 mg to
achieve 1000 mg PO bid
OR
• Micronase 2.5 mg PO qd after breakfast
(elderly 1.25 mg PO)
Third drug if needed
• Avandia 4 mg PO qd
OR
• Actos 30 mg PO qd
Elderly
Monotherapy
• Prandin 0.5–4 mg PO up to qid ac (not to
exceed 16 mg qd)
Monotherapy failure
• Consider switch to NPH insulin 10 units SQ
bedtime
Asians
Monotherapy
• Avandia 4 mg PO qd
OR
• Actos 30 mg PO
Second drug if needed
• Metformin 500 mg PO bid with or after meals
 1 week, increase weekly by 500 mg to
achieve 1000 mg PO bid
Third drug if needed
• Micronase 2.5 mg PO qd after breakfast
(elderly 1.25 mg PO)
Symptomatic patients
● Prandin 0.5–4 mg PO up to qid ac (not to exceed
16 mg qd) or insulin to decrease glucose at start
of monotherapy initiation