What is the immediate treatment for hypoglycemia (low blood sugar) in a patient who cannot tolerate oral (PO) intake?

Immediate Treatment for Hypoglycemia in Patients Unable to Tolerate Oral Intake

For patients with hypoglycemia who cannot tolerate oral intake, intravenous dextrose or intramuscular glucagon should be administered immediately, and emergency medical services should be activated. 1, 2

Assessment and Initial Management

• Hypoglycemia is defined as blood glucose <70 mg/dL (3.9 mmol/L), with symptoms typically developing when levels fall below 50-60 mg/dL (2.8-3.3 mmol/L) 1
• Symptoms include dizziness, fatigue, shakiness, tachycardia, confusion, slurred speech, and diaphoresis 1
• Significant hypoglycemia can lead to unconsciousness and seizures if untreated 1
• For patients unable to swallow or who are unconscious, oral glucose administration is contraindicated 1

Treatment Algorithm for Hypoglycemia in Patients Unable to Take PO

First-Line Treatment:

1. Intravenous Dextrose Administration:

   • 50% Dextrose (D50W) injection is indicated for insulin hypoglycemia to restore blood glucose levels 3
   • Administer intravenously under medical supervision 3

2. Intramuscular Glucagon:

   • For adults and pediatric patients weighing >25 kg or ≥6 years old: 1 mg (1 mL) injected intramuscularly into the upper arm, thigh, or buttocks 2
   • For pediatric patients weighing <25 kg or <6 years old: 0.5 mg (0.5 mL) injected intramuscularly 2
   • If no response after 15 minutes, an additional dose may be administered while waiting for emergency assistance 2

Monitoring and Follow-up:

• After treatment, monitor blood glucose levels at 15-minute intervals until normal levels (≥70 mg/dL) are restored 1
• When the patient regains consciousness and can swallow safely, provide oral carbohydrates to restore liver glycogen and prevent recurrence of hypoglycemia 2

Special Considerations

• Untreated hypoglycemia can cause seizures, status epilepticus, permanent brain injury, and death 1
• Hospital-related hypoglycemia is associated with higher mortality 1
• Common triggers for iatrogenic hypoglycemia include sudden reduction of corticosteroid dose, reduced oral intake, emesis, nothing-by-mouth status, inappropriate timing of insulin, reduced IV dextrose infusion rate, and unexpected interruption of feeding 1

Institutional Protocols

• Healthcare facilities should have standardized hospital-wide, nurse-initiated hypoglycemia treatment protocols in place 1
• Staff should be trained in the recognition and treatment of hypoglycemia 1
• Appropriate staff should be trained to administer glucagon 1
• Institutions should implement policies requiring staff to notify a physician of all blood glucose results outside specified ranges (e.g., <50 mg/dL) 1

Pitfalls and Caveats

• Do not attempt oral administration of glucose in patients who are unconscious or unable to swallow, as this poses a significant aspiration risk 1
• For children with suspected hypoglycemia who are awake but unwilling or unable to swallow glucose, a slurry of granulated sugar and water applied under the tongue may be reasonable, but this is not appropriate for unconscious patients 1
• Recurrent episodes of hypoglycemia can lead to hypoglycemia unawareness, creating a vicious cycle of further hypoglycemic events 4
• When transitioning from intravenous insulin therapy to subcutaneous insulin, give subcutaneous insulin 1-2 hours before discontinuing IV insulin to prevent rebound hypoglycemia 1