How is hypoglycemia (low blood sugar) managed in patients with sepsis?

Management of Hypoglycemia in Patients with Sepsis

Hypoglycemia in septic patients should be treated urgently with 30-50g of glucose, and blood glucose levels should be maintained above 70 mg/dL (4 mmol/L) while avoiding tight glycemic control that could trigger further hypoglycemic episodes. 1

Prevalence and Significance

Hypoglycemia is a serious complication in sepsis that requires immediate attention:

• Observed in approximately 16.3% of septic patients on hospital admission 1
• Independently associated with increased in-hospital mortality 1, 2
• Patients with severe hypoglycemia (≤40 mg/dL) have significantly higher mortality (71.4%) compared to euglycemic patients (8.7%) 2

Clinical Presentation and Risk Factors

Certain patient characteristics increase the risk of hypoglycemia in sepsis:

• Altered mental status (86% specificity for predicting hypoglycemia in septic patients) 1
• Specific infections, particularly malaria 1
• Limited glycogen stores (malnourished patients or those with liver disease) 1
• Certain pathogens (Streptococcus pneumoniae, Hemophilus influenzae) 3
• Metabolic acidosis, leukopenia, and abnormal clotting studies often accompany sepsis-associated hypoglycemia 3

Diagnostic Approach

• Check blood glucose levels immediately in all septic patients 1, 4
• If blood glucose testing is not immediately available in patients with altered mental status, make a presumptive diagnosis of hypoglycemia and treat accordingly 1
• For accurate measurements, use arterial blood rather than capillary blood for point-of-care testing if arterial catheters are available 1
• Be cautious with capillary blood glucose measurements as they may not accurately estimate arterial blood or plasma glucose values 1

Treatment Protocol

Immediate Management of Hypoglycemia:

1. For conscious patients:

   • Administer 15-20g of oral glucose 4
   • Recheck blood glucose after 15 minutes 4
   • Repeat treatment if hypoglycemia persists 4

2. For unconscious patients or those unable to take oral glucose:

   • Administer 30-50g of glucose intravenously urgently 1
   • For severe hypoglycemia, administer 25mL of 50% dextrose as a slow IV push 4
   • Alternative: Glucagon 1mg subcutaneously or intramuscularly for adults and pediatric patients weighing >25kg 5
   • For pediatric patients <25kg, administer 0.5mg glucagon 5

Ongoing Management:

• Provide a glucose calorie source (oral/enteral or intravenous) to prevent recurrent hypoglycemia 1
• Target blood glucose levels >70 mg/dL (>4 mmol/L) 1
• Do not target upper blood glucose levels <150 mg/dL (<8.3 mmol/L) as this increases risk of hypoglycemic events 1
• For hyperglycemia management, commence insulin dosing only when two consecutive blood glucose levels are >180 mg/dL 1
• Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours thereafter 1

Pitfalls and Caveats

1. Avoid tight glycemic control:

   • Targeting blood glucose levels of 80-100 mg/dL increases risk of harmful hypoglycemia 6
   • Less strict glycemic control with target blood glucose of 140-180 mg/dL is now recommended 1, 6

2. Recognize increased risk of glycemic variability:

   • The severity of sepsis correlates with both hyperglycemia and critical hypoglycemia risk 7
   • Glycemic variability itself is associated with increased mortality 8

3. Consider underlying factors:

   • Depleted glycogen stores, impaired gluconeogenesis, and increased peripheral glucose utilization may all contribute to hypoglycemia in sepsis 3
   • Special consideration should be given to diabetic patients with sepsis 6

4. Continue monitoring after initial treatment:

   • Even after resolution of hypoglycemia, patients require continued glucose monitoring 4
   • Investigate the underlying cause of hypoglycemia 4

By following these guidelines, clinicians can effectively manage hypoglycemia in septic patients while minimizing the risk of adverse outcomes associated with both hypoglycemia and overly aggressive glycemic control.