What is the further line of management for a patient with Type 2 Diabetes Mellitus (T2DM) who was admitted with hypoglycemia and altered sensorium, now has normalized blood glucose levels but persists with altered sensorium and is talking irrelevantly?

Management of Persistent Altered Sensorium in a T2DM Patient After Hypoglycemia Resolution

The patient with persistent altered sensorium despite normalized blood glucose levels requires urgent neurological evaluation and brain imaging to rule out cerebral edema, stroke, or hypoglycemic brain injury, which are life-threatening complications of severe hypoglycemia. 1

Immediate Assessment and Management

• Ensure airway, breathing, and circulation are stable 1
• Confirm blood glucose normalization with repeated measurements to ensure hypoglycemia has truly resolved 1
• Perform detailed neurological examination to assess level of consciousness, focal deficits, and signs of increased intracranial pressure 1
• Order urgent brain imaging (CT or MRI) to evaluate for cerebral edema, stroke, or hypoglycemic brain injury 1
• Consider electroencephalography (EEG) if seizure activity is suspected 1

Potential Causes of Persistent Altered Sensorium

• Hypoglycemic brain injury: Severe or prolonged hypoglycemia can cause neuronal damage that persists after glucose normalization 2
• Cerebral edema: Can develop as a complication of severe hypoglycemia or its treatment 1
• Post-hypoglycemic encephalopathy: Neurological symptoms that persist despite glucose correction 2
• Stroke: Hypoglycemia can trigger thromboembolic events, especially in patients with cardiovascular risk factors 1
• Metabolic derangements: Electrolyte abnormalities or renal dysfunction 1

Diagnostic Workup

• Complete metabolic panel to assess electrolytes, renal and liver function 1
• Arterial blood gas analysis to evaluate acid-base status 1
• Serum osmolality measurement 1
• Toxicology screen if substance use is suspected 1
• Consider lumbar puncture if meningitis/encephalitis is suspected (after ruling out increased intracranial pressure) 1

Treatment Approach

Immediate Interventions

• Maintain normoglycemia with careful glucose monitoring every 15-30 minutes initially 1
• Avoid overcorrection of glucose levels, aiming for target range of 5-10 mmol/L (90-180 mg/dL) 1
• Administer intravenous fluids if dehydration is present 1
• Consider mannitol or hypertonic saline if cerebral edema is suspected 1

Specific Management Based on Etiology

• If cerebral edema is confirmed:

  • Elevate head of bed to 30 degrees 1
  • Neurosurgical consultation for severe cases 1
  • Consider osmotic therapy with mannitol 1

• If stroke is diagnosed:

  • Implement appropriate stroke protocol based on type (ischemic vs. hemorrhagic) 1
  • Neurology consultation 1

• If metabolic derangement is identified:

  • Correct electrolyte abnormalities 1
  • Address renal dysfunction if present 1

Supportive Care

• Maintain adequate oxygenation 1
• Consider prophylactic anticonvulsants if seizures are suspected 1
• Implement measures to prevent aspiration pneumonia 1
• Monitor vital signs and neurological status frequently 1

Prevention of Recurrent Hypoglycemia

• Adjust diabetes medications to prevent future hypoglycemic episodes 1
• Consider relaxing glycemic targets temporarily to avoid recurrent hypoglycemia 1
• Provide diabetes education to patient and family once patient recovers 1
• Consider continuous glucose monitoring if appropriate 1

Follow-up Care

• Neuropsychological assessment once patient stabilizes to evaluate cognitive function 2
• Rehabilitation services if neurological deficits persist 1
• Adjustment of diabetes management plan with emphasis on hypoglycemia prevention 1
• Regular follow-up to monitor neurological recovery 1

Pitfalls to Avoid

• Do not assume altered mental status is solely due to hypoglycemia if blood glucose has normalized 2
• Avoid excessive glucose administration once normoglycemia is achieved, as it may worsen cerebral edema 1
• Do not delay neuroimaging in a patient with persistent neurological symptoms 1
• Recognize that elderly patients and those with long-standing diabetes are at higher risk for prolonged neurological symptoms after hypoglycemia 2, 3