What is the management of hypoglycemia (low blood sugar) in a hospital setting?

Management of Hypoglycemia in the Hospital

Implement a standardized, nurse-initiated hypoglycemia treatment protocol hospital-wide that immediately addresses any blood glucose <70 mg/dL (3.9 mmol/L) with 15-20 grams of oral glucose for conscious patients or intravenous dextrose/intramuscular glucagon for unconscious patients, followed by mandatory review and adjustment of the treatment regimen to prevent recurrence. 1, 2, 3

Immediate Treatment Protocol

For Conscious Patients Who Can Swallow

• Administer 15-20 grams of oral glucose immediately as the preferred first-line treatment 1, 4, 2, 3
• Recheck blood glucose after 15 minutes 1, 4, 2, 3
• Repeat treatment with another 15-20 grams of glucose if blood glucose remains <70 mg/dL 2, 3
• Once glucose normalizes (>70 mg/dL), provide a meal or snack to prevent recurrence 1, 4, 2

For Unconscious or Severely Impaired Patients

• Administer 10-20 grams of intravenous 50% dextrose (20-40 mL) immediately for patients with altered mental status 4, 3, 5
• Alternative: Administer 1 mg intramuscular or subcutaneous glucagon if IV access is not available 1, 5
  • For pediatric patients <25 kg or <6 years: use 0.5 mg glucagon 5
  • For adults and children ≥25 kg or ≥6 years: use 1 mg glucagon 5
• Stop any insulin infusion immediately 4
• Recheck blood glucose every 15 minutes until levels exceed 70 mg/dL 1, 4, 3
• If no response after 15 minutes, administer an additional dose while waiting for emergency assistance 5

Critical caveat: Recovery of consciousness after glucagon is slower than after dextrose (6.5 vs 4.0 minutes), though both are effective 6. Dextrose 10% may be as effective as dextrose 50% with fewer adverse events and less post-treatment hyperglycemia, though it takes approximately 4 minutes longer to achieve symptom resolution 7.

Mandatory Post-Event Actions

Immediate Documentation and Review

• Document every hypoglycemic episode in the medical record and track for quality improvement 1
• Review and modify the treatment regimen whenever blood glucose <70 mg/dL is documented 1, 3
• Notify physician of all blood glucose results outside specified range (e.g., <50 mg/dL) 1

Prevention of Recurrence

• Identify and address triggering events: sudden reduction of corticosteroid dose, reduced oral intake, emesis, new NPO status, inappropriate timing of insulin relative to meals, reduced IV dextrose infusion rate, or unexpected interruption of enteral/parenteral nutrition 1
• Identify predisposing conditions: renal or liver disease, heart failure, malignancy, infection, sepsis, or altered nutritional state 1
• For patients with prior severe hypoglycemia, 84% had a preceding episode of hypoglycemia <70 mg/dL during the same admission, making this a critical predictor 1

Prevention Strategies

Insulin Management

• Outside critical care units, use scheduled subcutaneous insulin regimens (basal-bolus or basal-plus-correction), not sliding scale insulin alone 1
• For patients with poor oral intake or NPO status, use basal insulin or basal-plus-correction regimen 1
• For type 1 diabetes patients, never hold basal insulin even when NPO 2
• When transitioning from IV to subcutaneous insulin, administer basal insulin 2 hours before discontinuing IV infusion 2

Nutrition-Insulin Matching

• Align insulin injections with meals for patients who are eating 1
• Perform point-of-care glucose monitoring immediately before meals 1
• For abrupt interruption of caloric intake, consider preventive IV dextrose when glucose falls to 120 mg/dL (within the time frame of previously administered antihyperglycemic drugs) 8

High-Risk Patient Identification

• Identify patients at greater risk: those on insulin or sulfonylurea therapy, history of severe hypoglycemia, renal insufficiency, cognitive impairment 1
• Consider housing high-risk patients closer to medical units to minimize treatment delays 1

Staff Training Requirements

All hospital staff supervising patients at risk for hypoglycemia must be trained in: 1

• Recognition of hypoglycemia symptoms and signs
• Emergency treatment protocols
• Glucagon administration technique
• Appropriate medical referral procedures

Target Blood Glucose After Treatment

• Achieve blood glucose >70 mg/dL (3.9 mmol/L) 4, 3
• Avoid overcorrection causing iatrogenic hyperglycemia 4
• For hospitalized non-critically ill patients, maintain 100-180 mg/dL 4

Common pitfall: Insulin is one of the most common drugs causing adverse events in hospitalized patients, with errors in dosing and administration occurring frequently 1. The most preventable sources of iatrogenic hypoglycemia are improper prescribing, inappropriate management of the first hypoglycemic episode, and nutrition-insulin mismatch 1.