What are the guidelines for administering a glucagon drip in severe hypoglycemia?

Guidelines for Administering a Glucagon Drip in Severe Hypoglycemia

For severe hypoglycemia unresponsive to standard treatments, a glucagon infusion can be administered at 1-5 mcg/minute after an initial bolus of 1 mg IV (for adults and children ≥20 kg) or 0.5 mg (for children <20 kg), with hourly glucose monitoring and titration based on response.

Initial Management of Severe Hypoglycemia

First-Line Treatment Options

• Conscious patients with intact swallowing: 15-20g oral glucose (preferred) or any carbohydrate-containing food 1

  • Recheck blood glucose after 15 minutes
  • Repeat treatment if hypoglycemia persists
  • Follow with meal or snack once glucose normalizes

• Unconscious patients or those unable to swallow safely:

  • Glucagon administration (preferred for out-of-hospital settings) 1:
    • Adults and children >25kg: 1mg subcutaneously or intramuscularly
    • Children <25kg: 0.5mg subcutaneously or intramuscularly
  • IV glucose: 20-40 mL of 50% glucose solution (in hospital settings) 1

Glucagon Drip Protocol for Persistent Severe Hypoglycemia

Indications

• Persistent severe hypoglycemia unresponsive to initial treatment
• Inability to maintain euglycemia with oral intake or IV dextrose

Dosing for IV Glucagon Infusion 2, 3

1. Initial bolus dose:

   • Adults and children ≥20 kg: 1 mg IV
   • Children <20 kg: 0.5 mg or 20-30 mcg/kg IV

2. Continuous infusion rate:

   • Start at 1-5 mcg/minute
   • Titrate based on blood glucose response

Monitoring During Infusion 1, 2

• Hourly vital signs (heart rate, respiratory rate, blood pressure)
• Hourly capillary blood glucose measurements
• Electrolytes, blood glucose, and blood gases every 2-4 hours
• Continuous cardiac monitoring for arrhythmias

Transition from IV Glucagon 2

• Once blood glucose stabilizes >70 mg/dL, provide oral carbohydrates if patient is conscious
• Taper glucagon infusion gradually while monitoring glucose response
• Ensure patient receives a meal or snack to prevent recurrence

Special Considerations

Potential Side Effects

• Nausea and vomiting (common)
• Headache
• Tachycardia
• Hypokalemia (monitor electrolytes)

Precautions

• Avoid rapid administration of concentrated dextrose solutions as this has been associated with cardiac arrest and hyperkalemia 1
• For patients with recurrent severe hypoglycemia, consider:
  • Reevaluating treatment regimen 1
  • Temporarily raising glycemic targets for several weeks to reverse hypoglycemia unawareness 1
  • Switching from sulfonylureas to non-hypoglycemic agents if applicable 1
  • Using insulin analogs rather than human insulins to minimize hypoglycemia risk 1

Facility Protocols

• Healthcare facilities should have protocols in place for prompt recognition and treatment of severe hypoglycemia 2
• Staff should be trained to recognize symptoms of serious metabolic decompensation
• Glucagon should be readily available in areas where patients at risk for hypoglycemia are treated

Prevention of Recurrent Hypoglycemia

• Identify and address the cause of hypoglycemia
• Review medication dosing, recent food intake patterns, and physical activity levels
• Consider CGM for patients with recurrent hypoglycemia or hypoglycemia unawareness 1
• Provide structured education on hypoglycemia prevention and treatment 1

Remember that while glucagon drips are effective for severe, persistent hypoglycemia, they should be used as part of a comprehensive approach that includes identifying and addressing the underlying cause of hypoglycemia to prevent recurrence.