When should hypoglycemia be treated in cardiac arrest?

From the Guidelines

Hypoglycemia should be treated in cardiac arrest when blood glucose levels are confirmed to be low (typically less than 70 mg/dL or 3.9 mmol/L) after initial resuscitation efforts have begun. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of maintaining adequate blood glucose levels during cardiac arrest to support brain and heart function 1.

Treatment Approach

Treatment involves administering 50 mL of 50% dextrose (D50W) as an IV bolus, which provides 25 grams of glucose. If IV access is not available, glucagon 1 mg can be administered intramuscularly or subcutaneously. After initial treatment, blood glucose should be rechecked within 10-15 minutes, and additional doses may be given if hypoglycemia persists. It is crucial that addressing hypoglycemia does not delay or interrupt critical resuscitation measures like chest compressions, defibrillation, or airway management.

Rationale

The rationale for treating hypoglycemia during cardiac arrest is that the brain and heart require glucose for proper function, and severe hypoglycemia can trigger or worsen cardiac arrhythmias and impair myocardial contractility. Additionally, hypoglycemia can hinder successful resuscitation and neurological recovery even if spontaneous circulation is restored. The European Resuscitation Council and European Society of Intensive Care Medicine guidelines from 2015 support avoiding strict glucose control and maintaining blood glucose at ≤180 mg/dL to avoid hypoglycemia 1.

Key Considerations

• Blood Glucose Targets: The goal is to maintain blood glucose levels above 70 mg/dL (3.9 mmol/L) without implementing strict glucose control, which can increase the risk of hypoglycemia 1.
• Treatment Timing: Treatment should not delay critical resuscitation efforts.
• Monitoring: Regular monitoring of blood glucose levels is essential to guide treatment and prevent recurrence of hypoglycemia.

By following these guidelines and prioritizing the maintenance of adequate blood glucose levels, healthcare providers can optimize the management of hypoglycemia during cardiac arrest, potentially improving patient outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Administer Glucagon for Injection as soon as possible when severe hypoglycemia is recognized The FDA drug label does not answer the question of when to treat hypoglycemia in cardiac arrest.

From the Research

Treatment of Hypoglycemia in Cardiac Arrest

• Hypoglycemia is a reversible cause of cardiac arrest, but its treatment has been debated in recent years 2, 3.
• The American Heart Association ACLS guidelines removed hypoglycemia from the "H's and T's" in subsequent editions after 2005, but it is still important to consider and correct hypoglycemia if noted 2.
• Routine administration of dextrose to patients in cardiac arrest has been associated with increased mortality and worse neurological outcomes, suggesting that treatment of hypoglycemia should be targeted and not routine 2, 3.

Incidence and Outcomes of Hypoglycemia in Cardiac Arrest

• The incidence of hypoglycemia in out-of-hospital cardiac arrests (OHCA) is around 7%, and only 41% of hypoglycemic patients receive dextrose and/or glucagon 3.
• Field return of spontaneous circulation (ROSC) was achieved in 30% of hypoglycemic patients who received treatment, but survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia 3.
• Hypoglycemia during the 48 hours after return of spontaneous circulation (ROSC) was independently associated with poor neurologic outcomes, highlighting the need for careful glucose management in cardiac arrest patients 4.

Glucose Management in Cardiac Arrest

• Hyperglycemia is commonly observed in critically ill patients and postcardiac arrest patients, and higher glucose levels and variability are associated with poorer outcomes 4, 5.
• A glucose management protocol to maintain arterial blood glucose levels between 140 and 180 mg/dL using short-acting insulin infusion may be beneficial in cardiac arrest patients 4.
• Blood glucose level at admission is associated with survival and favorable neurologic outcomes at hospital discharge in patients treated with therapeutic hypothermia after cardiac arrest, suggesting that glucose control is an important aspect of cardiac arrest management 5.