How to maintain Intravenous Fluids (IVF) for a patient with recurrent hypoglycemia during admission?

From the Guidelines

For a patient with recurrent hypoglycemia during admission, I recommend maintaining intravenous fluids (IVF) with D10W (10% dextrose in water) at a rate of 75-125 mL/hour, adjusting based on blood glucose monitoring every 1-2 hours until stability is achieved, as supported by the most recent guidelines 1.

Key Considerations

• The treatment of hypoglycemia should prioritize the administration of glucose (15–20 g) for conscious individuals, with any form of carbohydrate that contains glucose being acceptable 1.
• For severe hypoglycemia (blood glucose <50 mg/dL), a 50 mL bolus of D50W (50% dextrose) followed by D10W infusion is recommended.
• Once the patient stabilizes, transition to D5W (5% dextrose) at 75-100 mL/hour while investigating the underlying cause of hypoglycemia, which may include excessive insulin administration, oral hypoglycemic agents, decreased oral intake, liver dysfunction, sepsis, or adrenal insufficiency 1.

Management and Prevention

• Address the underlying etiology while maintaining IVF support, and consider adding potassium (20-40 mEq/L) to the IVF if levels are low.
• Nutritional support should be initiated as soon as possible, with enteral feeding preferred over parenteral when feasible.
• The goal is to maintain blood glucose between 100-180 mg/dL while treating the primary cause of hypoglycemia, as per recent inpatient studies 1.
• Recent guidelines also recommend the use of personal continuous glucose monitoring (CGM) and automated insulin delivery (AID) devices as an early warning system to alert of impending hypoglycemia 1.

Monitoring and Adjustment

• Blood glucose monitoring should be performed every 1-2 hours until stability is achieved, with adjustments made to the IVF rate as needed.
• Electrolytes, renal function, venous pH, osmolality, and glucose should be checked every 2–4 h until stable, as recommended in the latest standards of care 1.

From the FDA Drug Label

Glucagon for Injection is indicated for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes mellitus. Administer intravenously ONLY under medical supervision. The recommended dosage is 1 mg (1 mL) injected subcutaneously or intramuscularly into the upper arm, thigh, or buttocks. Alternatively, healthcare providers may administer the dose intravenously

The patient with recurrent hypoglycemia in admission can be maintained on IV glucagon as needed, with a recommended dose of 1 mg (1 mL) administered intravenously by a healthcare provider, and repeated as necessary if there is no response after 15 minutes. It is crucial to monitor the patient closely and provide oral carbohydrates when the patient is able to swallow to restore liver glycogen and prevent recurrence of hypoglycemia 2.

From the Research

Maintaining IVF for Patient with Recurrent Hypoglycemia in Admission

• The management of recurrent hypoglycemia in patients is crucial, especially in those undergoing IVF treatment, as it can impact the outcome of the treatment 3.
• A study published in 2015 found that the administration of D50W per protocol resulted in a 6.8% rate of overcorrection, and 49% of hypoglycemic episodes corrected to a BG >100 mg/dL 4.
• The same study also found that a multivariable GEE analysis showed a significantly higher BG response in participants with diabetes, but a lower response in those with recurrent hypoglycemia 4.
• Another study published in 2018 found that system-based interventions, including standardized reporting and management, can reduce the incidence of severe hypoglycemic events in hospitalized patients with diabetes 5.
• The study also found that the median time from hypoglycemic event to euglycemia declined from 225±46 min preintervention to 87±26 min postintervention, and the median time from hypoglycemic event to next finger-stick testing also declined 5.

Treatment and Prevention of Hypoglycemia

• Treatment of hypoglycemia typically involves the administration of glucose or glucagon, and prevention strategies include patient education, setting personalized goals for glycemic control, and regular review with healthcare professionals 3, 6.
• A review published in 2021 found that impairments in counterregulatory responses and hypoglycemia unawareness constitute the main risk factors for severe hypoglycemia, and that episodes of hypoglycemia are associated with physical and psychological morbidity 3.
• Another review published in 2020 found that education and regular review are essential between people with diabetes and their caregivers and healthcare professionals about symptoms, prevention, and treatment of hypoglycemia 6.

Emergency Treatment of Hypoglycemia

• A guideline and evidence review published in 2017 found that high-quality evidence for the management of hypoglycemia was lacking, limiting treatment recommendations, but generally recommended 15-20 g of oral glucose or sucrose, repeated after 10-15 min for treatment of the responsive adult, and 10% intravenous dextrose or 1 mg intramuscular glucagon for treatment of the unresponsive adult 7.
• The review also found that evidence for the emergency treatment of hypoglycemia in adults is limited, is often low grade, and mostly pre-dates contemporary management of diabetes 7.