How to manage a patient with hypoglycemia?

Management of Hypoglycemia (Blood Glucose 36 mg/dL)

Immediate administration of 15-20g of fast-acting oral glucose is the first-line treatment for this severe hypoglycemia, followed by blood glucose reassessment after 15 minutes and additional treatment if needed. 1

Immediate Management Algorithm

1. Assess consciousness and ability to swallow

   • If conscious and able to swallow:
     • Administer 15-20g of fast-acting carbohydrates (4-8 oz juice/soda, 3-4 glucose tablets) 2, 1
     • Recheck blood glucose after 15 minutes
     • If still <70 mg/dL, repeat treatment
     • Once >70 mg/dL, provide a meal or snack containing complex carbohydrates and protein

2. If unconscious or unable to swallow:

   • Administer glucagon:
     • Adults and children >25kg: 1mg subcutaneously or intramuscularly 3
     • Children <25kg: 0.5mg subcutaneously or intramuscularly 3
   • Position patient on side to prevent aspiration
   • Call for emergency assistance immediately after administering glucagon 3
   • Once patient regains consciousness, provide oral carbohydrates to prevent recurrence 3

Post-Hypoglycemia Management

Immediate Follow-up (Next 24 hours)

• Monitor blood glucose every 1-2 hours until stable
• Identify and address the cause of hypoglycemia:
  • Insulin dosing errors
  • Missed/delayed meals
  • Unexpected physical activity
  • Alcohol consumption
  • Medication interactions
  • Reduced oral intake or emesis 2

Hospital Setting Considerations

• Implement a standardized hospital-wide hypoglycemia treatment protocol 2
• Review treatment regimen when blood glucose <70 mg/dL is documented 2
• Document episodes in medical record for quality improvement tracking 2
• Consider common iatrogenic causes: improper medication prescribing, inappropriate management of first hypoglycemic episode, and nutrition-insulin mismatch 2

Prevention of Recurrent Hypoglycemia

Medication Adjustments

• Review and potentially reduce insulin or insulin secretagogue doses
• Consider transition from intermediate-acting insulin to more physiologic long-acting insulins, as intermediate-acting insulin peaks can cause hypoglycemia if meals are delayed 2
• For patients on insulin with frequent hypoglycemia, consider raising short-term blood glucose targets to improve hypoglycemia awareness 2

Patient Education

• Teach recognition of hypoglycemia symptoms
• Instruct on proper carbohydrate intake with insulin administration
• Recommend consistent carbohydrate meal plans 2
• Advise always carrying a source of sugar (glucose tablets, candy) 2
• Recommend medical alert bracelet/necklace 2

Special Considerations

• A history of severe hypoglycemia increases risk for subsequent episodes 4
• Short-term avoidance of hypoglycemia (2-3 weeks) can reverse hypoglycemia unawareness 4
• Hypoglycemia unawareness requires more frequent monitoring and higher glycemic targets 2

Common Pitfalls to Avoid

• Overtreatment of hypoglycemia leading to rebound hyperglycemia
• Failure to identify and address the underlying cause
• Not reducing insulin doses when adding other glucose-lowering medications 1
• Using sliding-scale insulin alone in hospital settings 2
• Neglecting to educate family members/caregivers about glucagon administration 2
• Failing to recognize that a prior episode of hypoglycemia increases risk for subsequent episodes 2

This severe hypoglycemia (36 mg/dL) requires immediate treatment and careful follow-up to prevent recurrence and potentially life-threatening complications. The approach must balance immediate correction with identifying and addressing the underlying cause.