How do you manage hypoglycemia-induced seizure in a hospitalized patient with a Do Not Resuscitate (DNR) order?

Management of Hypoglycemia-Induced Seizure in Hospitalized Patients with DNR Orders

For hypoglycemia-induced seizures in hospitalized patients with DNR orders, immediate administration of IV dextrose (D50) is the first-line treatment to rapidly correct blood glucose levels and terminate the seizure, while respecting the DNR status which does not preclude treatment of reversible conditions like hypoglycemia. 1, 2

Differential Diagnoses for Hypoglycemia in Hospitalized Patients

• Iatrogenic causes (most common): insulin dosing errors, improper prescribing of glucose-lowering medications, inappropriate management of previous hypoglycemic episodes 1
• Nutrition-insulin mismatch: unexpected interruption of enteral/parenteral nutrition, reduced oral intake, emesis, NPO status 1
• Medication-related: sudden reduction in corticosteroid dose, inappropriate timing of short/rapid-acting insulin relative to meals 1
• Altered metabolism: acute kidney injury (decreased insulin clearance), renal failure, sepsis, liver disease 1
• Reduced counterregulatory responses: especially in elderly patients who may have impaired glucagon and epinephrine release in response to hypoglycemia 1
• Malnutrition and low albumin levels: particularly in elderly patients 1

Acute Management of Hypoglycemia-Induced Seizure

Immediate Interventions (Compatible with DNR Status)

• Administer 50% dextrose (D50) 25-50 mL IV push as first-line treatment to rapidly raise blood glucose 1, 2
• If IV access is unavailable, administer glucagon 1 mg IM/SC (note: less effective in malnourished patients with depleted glycogen stores) 1
• Check blood glucose every 15 minutes until stabilized above 100 mg/dL 1
• Follow with continuous glucose infusion (D10W) if needed to maintain euglycemia 3
• Document the episode in the medical record for quality improvement tracking 1

DNR Considerations

• DNR orders do not preclude treatment of reversible conditions like hypoglycemia or seizures 1
• Treatment of hypoglycemia-induced seizure is consistent with providing comfort care and preventing suffering 1
• Avoid unnecessary intubation or mechanical ventilation if these interventions conflict with the patient's DNR status 1

Post-Seizure Management

• Review the entire treatment regimen when any blood glucose value is <70 mg/dL, as this predicts subsequent severe hypoglycemia 1
• Identify and address the root cause of hypoglycemia to prevent recurrence 1
• Monitor for neurological sequelae as hypoglycemia can cause focal neurological deficits that may mimic stroke 4, 5
• Consider EEG monitoring if seizure activity is prolonged or recurrent, as hypoglycemia can trigger focal seizures, particularly of temporal origin 4

Long-Term Prevention Plan

Insulin Regimen Adjustments

• Reduce basal insulin doses by 20-30% if recurrent hypoglycemia occurs 1
• Use basal-bolus insulin regimens rather than sliding scale insulin alone, which is strongly discouraged 1, 6
• Consider lower insulin doses for patients with renal insufficiency 1
• Ensure proper timing of insulin administration relative to meals 1

Nutritional Considerations

• Implement consistent carbohydrate meal plans to facilitate matching prandial insulin to carbohydrate intake 1
• Involve a registered dietitian to integrate information about the patient's clinical condition, meal planning, and lifestyle habits 1
• For patients on enteral/parenteral nutrition, ensure insulin regimen includes coverage of basal, prandial, and correctional needs 1
• Coordinate meal delivery and insulin administration to prevent mismatches 1

Monitoring and System Improvements

• Implement "bundled" preventive therapies including proactive surveillance of glycemic outliers, which can reduce hypoglycemic events by 56-80% 1
• Establish a standardized hospital-wide nurse-initiated hypoglycemia treatment protocol 1
• Develop individualized plans for preventing hypoglycemia for each patient 1
• Consider using predictive algorithms for identifying patients at high risk of hypoglycemia 1

Special Considerations for Patients with DNR Orders

• Clarify the scope of the DNR order with the patient/family to understand which interventions are acceptable 1
• Document discussions about goals of care related to diabetes management in the context of DNR status 1
• Balance glycemic targets with quality of life considerations, potentially accepting higher glucose targets (180-200 mg/dL) to minimize hypoglycemia risk 1
• Prioritize symptom management and comfort while still treating reversible conditions like hypoglycemia 1

Common Pitfalls to Avoid

• Assuming DNR means "do not treat" - DNR orders specifically address cardiopulmonary resuscitation, not other treatments 1
• Relying solely on sliding scale insulin without basal insulin, which is ineffective and increases hypoglycemia risk 1, 6
• Failing to adjust insulin doses after the first hypoglycemic episode 1
• Overlooking nutrition-insulin mismatches when nutrition is interrupted 1
• Mistaking hypoglycemia symptoms for other conditions like stroke or head trauma 5