Hypoglycemia & Hyperglycemia
Dave Joffe, BSPharm, CDE, FACA
Part 4
Hypoglycemia- in the hospital
 May be associated with specific conditions in
hospitalized patient populations:
 Renal failure
 Heart failure
 Infection
 Sepsis
 Decrease in glucocorticoid use
 Decreased oral intake or alteration in enteral or
parenteral nutrition
Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.
Campbell KB, Braithwaite SS. Hospital Management of Hyperglycemia. Clinical Diabetes. 2004;22:81-88.
Hypoglycemia Prevention
 Frequent blood glucose monitoring
 Glucose levels should be monitored hourly until
levels are stable
 After stabilization of glucose levels, monitoring
may be performed every 2-4 hours
 Adjustment of prandial insulin doses to account for
alterations in oral intake
 Adjustment of basal and prandial insulin TDD
during high dose glucocorticoid administration: 30%
basal insulin and 70% prandial insulin
Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591
Campbell KB, Braithwaite SS. Hospital Management of Hyperglycemia. Clinical Diabetes. 2004;22:81-88
Hypoglycemia
 Patients Responsive:
Administer oral carbohydrate. Recheck blood glucose
in 15 minutes and if blood glucose > 70 administer meal 30 minutes after.
 Patient NPO Responsive:
Either establish IV access and administer 10-20g
of 50% Dextrose OR administer 1g Glucagon IM. Recheck blood glucose every 15
minutes and administer carbohydrate again (PO or IV)if blood glucose is not greater
then 70mg/dL.
 Patient Nonresponsive:
Establish IV access and administer 25g of 50%
Dextrose OR administer 1g Glucagon IM. Check glucose in 15 minutes and if not >
70mg/dL then follow physicians orders.
Insulin Disaster
 Patient initiated on feeding tube at noon and her blood
glucose was 418
 Normal dose of insulin and at 2 pm her blood glucose
was 453
 Physician ordered 10 units of regular insulin to be given
IV
 The nurse gave the 10 mL quantity of insulin to the
patient, therefore giving 1,000 units of insulin at 3 pm
Insulin Disaster
 By 5:55 pm, the patients blood sugar was 102 and
oxygen + tube feeding continued
 At 8:55 pm, blood glucose 78 and at 9:25 pm blood
glucose 87
 By 9:30 pm, the patient did not have an audible heart
rate and was not breathing
 The patient died at 9:45 pm despite CPR
Prevention of Error
 Develop a facility plan on how to treat hypoglycemia
and insulin overdose based on amount of insulin given
 Education of staff on proper administration and potency
of insulin
 Recognize different measurements and create
standardization of ordering by using only one
measurement, i.e. “units”
Hyperglycemia: Pathophysiology
 Abnormal utilization of glucose in the body
 Resistance in tissues
 Not enough insulin present to get glucose into the cell
 Continuously high levels of glucose in the body lead to
macrovascular & microvascular complications
 Excess glucose begins to spill over into urine
 When the brain is not able to utilize the glucose it begins
converting fats into an energy source it can use
 Produces ketones
 Ketoacidosis is the buildup of ketones in the blood which can
cause shortness of breath, nausea, vomiting, and very dry
mouth.
Hyperglycemia: The Values
Lab Glucose Value:
Effects:
>180 mg/dl or >200 mg/dl
• Typical renal threshold, although
varies from person to person
>400 mg/dl
• Deemed critical hyperglycemia
 Consistent levels >126 mg/dl indicate chronic hyperglycemia
 Patients educated to seek medical attention if glucose values
are persistently above 240 mg/dl
Hyperglycemia: The Causes
 Diabetes Mellitus (most common cause)
 Critical illness
 Physical trauma, surgery, MI, stroke, ect.
 Physiological Stress
 Presence of infection or inflammation
 Via endogenous catecholamines