Inpatient Hypoglycemia Management Protocol
Immediate Treatment Based on Patient Consciousness Level
For conscious patients who can swallow, administer 15-20 grams of oral glucose immediately as first-line treatment, then recheck blood glucose after 15 minutes and repeat the same dose if glucose remains <70 mg/dL. 1
For unconscious or severely impaired patients, immediately administer 10-20 grams of IV 50% dextrose (20-40 mL) as the preferred treatment. 1 If IV access is unavailable, give 1 mg intramuscular or subcutaneous glucagon for adults and children ≥25 kg or ≥6 years, or 0.5 mg for pediatric patients <25 kg or <6 years. 1, 2
Post-Treatment Steps
- Once glucose normalizes (>70 mg/dL), provide a meal or snack immediately to prevent recurrence. 1
- Target blood glucose >70 mg/dL and avoid overcorrection causing iatrogenic hyperglycemia. 1
- For hospitalized non-critically ill patients, maintain glucose between 100-180 mg/dL. 1
Mandatory Documentation and Physician Notification
Every hypoglycemic episode must be documented in the medical record with tracking for quality improvement, and the treatment regimen must be reviewed and modified whenever blood glucose <70 mg/dL is documented. 1 Notify the physician immediately of all blood glucose results <50 mg/dL. 1
Critical Root Cause Analysis
After any hypoglycemic event, systematically identify triggering events: 1
- Sudden reduction of corticosteroid dose
- Reduced oral intake, emesis, or new NPO status
- Inappropriate timing of insulin relative to meals
- Reduced IV dextrose infusion rate
- Unexpected interruption of enteral/parenteral nutrition
Identify predisposing conditions: 1
- Renal or liver disease
- Heart failure
- Malignancy, infection, or sepsis
- Altered nutritional state
A critical predictor: 84% of patients with severe hypoglycemia had a preceding episode of hypoglycemia <70 mg/dL during the same admission. 1 This makes any documented hypoglycemia a red flag requiring immediate regimen modification.
Prevention Protocol: Insulin Regimen Changes
Use scheduled subcutaneous insulin regimens (basal-bolus or basal-plus-correction) outside critical care units—never use sliding scale insulin alone. 1, 3 This is strongly discouraged and associated with worse outcomes. 4
For patients with poor oral intake or NPO status: 1
- Use basal insulin or basal-plus-correction regimen
- Never hold basal insulin in type 1 diabetes patients, even when NPO 3
- Align insulin injections with meals for patients who are eating
- Perform point-of-care glucose monitoring immediately before meals
High-Risk Patient Identification and Management
Identify patients at greater risk: 1
- On insulin or sulfonylurea therapy
- History of severe hypoglycemia
- Renal insufficiency
- Cognitive impairment
Consider housing high-risk patients closer to medical units to minimize treatment delays. 1 Screen for impaired hypoglycemia awareness at least annually using validated tools like Clarke score, Gold score, or Pedersen-Bjergaard score. 3
Transition of Care Considerations
When transitioning from IV to subcutaneous insulin, administer basal insulin 2 hours before discontinuing IV infusion to prevent rebound hypoglycemia. 3 After abruptly withdrawing concentrated dextrose infusion, follow with 5% or 10% dextrose injection to avoid rebound hypoglycemia. 5
Staff Training Requirements
All hospital staff supervising patients at risk for hypoglycemia must be trained in recognition of hypoglycemia symptoms and signs, emergency treatment protocols, and appropriate medical referral procedures. 1 This is non-negotiable for patient safety.
Common Pitfalls to Avoid
- Provider response to hypoglycemia is suboptimal: Only 40% of patients receive treatment changes after hypoglycemia, and specialists agree with these changes only 52% of the time. 6 This represents a critical quality gap.
- Do not use concentrated dextrose solutions subcutaneously or intramuscularly—only IV, IM (for glucagon), or oral routes are appropriate. 5
- Hypoglycemia is associated with 22-27% mortality in hospitalized patients with diabetes, though it may be a marker for illness severity rather than directly causal. 7, 8