What is the immediate management for a patient admitted with hypoglycemia?

Immediate Management of Hypoglycemia on Admission

For patients admitted with hypoglycemia, immediately check blood glucose and administer 15-20 grams of oral glucose if the patient is conscious and able to swallow, or give 10-20 grams of IV 50% dextrose if the patient has altered mental status, is unconscious, or cannot safely swallow. 1, 2

Initial Assessment and Treatment Algorithm

Step 1: Assess Level of Consciousness and Ability to Swallow

Conscious patients who can follow commands and swallow safely:

• Administer 15-20 grams of oral glucose immediately (glucose tablets preferred) 3, 1
• Alternative sources if glucose tablets unavailable: fruit juice, regular soda, sports drinks, or hard candy 1
• Critical exception: If patient is taking α-glucosidase inhibitors, use ONLY glucose tablets or monosaccharides, as these drugs prevent digestion of complex carbohydrates and will delay treatment effectiveness 1

Unconscious, seizing, or unable to follow commands:

• Call for emergency assistance immediately 3
• If IV access available: Administer 10-20 grams of IV 50% dextrose, titrated based on initial glucose value 2
• If no IV access: Administer glucagon 1 mg IM (for patients >25 kg) or 0.5 mg IM (for patients ≤25 kg) into upper arm, thigh, or buttocks 2, 4, 5
• Never attempt oral glucose in unconscious or seizing patients due to aspiration risk 2, 4

Step 2: Recheck Blood Glucose After 15 Minutes

• Monitor blood glucose every 15 minutes until levels exceed 70 mg/dL 1, 2
• If hypoglycemia persists (glucose still <70 mg/dL), repeat treatment with same dose 1, 2
• For IV dextrose: A 25-gram dose produces blood glucose increases of approximately 162 mg/dL at 5 minutes and 63.5 mg/dL at 15 minutes 2
• Avoid overcorrection causing iatrogenic hyperglycemia 2

Step 3: Provide Follow-Up Carbohydrates

• Once blood glucose returns to normal (>70 mg/dL) and patient can swallow, give a meal or protein-containing snack to restore liver glycogen and prevent recurrence 1, 2, 4
• This step is critical even after successful initial treatment 1

Blood Glucose Monitoring Orders

Frequency of monitoring:

• Check blood glucose immediately on admission to confirm diagnosis 3
• Recheck every 15 minutes until glucose stabilizes above 70 mg/dL 1, 2
• After stabilization, continue monitoring at intervals appropriate to risk level and medication regimen 1

Target glucose ranges post-treatment:

• Immediate target: >70 mg/dL (3.9 mmol/L) 2
• For hospitalized critically ill patients: 140-180 mg/dL 2
• For noncritically ill hospitalized patients: 100-180 mg/dL 2

High-Risk Features Requiring Intensive Monitoring

Identify patients requiring more frequent monitoring: 2, 6

• History of recurrent severe hypoglycemia or hypoglycemia unawareness
• Concurrent illness, sepsis, hepatic failure, or renal failure
• Recent reduction in corticosteroid dose
• Altered nutritional intake
• Advanced age (>60 years)
• Medications: insulin, sulfonylureas, or insulin secretagogues 3, 1

Medication Management on Admission

Immediate actions:

• Stop any insulin infusion if present 2
• Hold or adjust doses of insulin, sulfonylureas, or meglitinides 1
• Review all medications that may contribute to hypoglycemia 1

Precipitating factors to document:

• Delayed or skipped meals 1
• Increased physical activity without dose adjustment 1
• Alcohol consumption 1
• Declining renal function 1

Critical Pitfalls to Avoid

• Do not delay treatment to obtain blood glucose if hypoglycemia is suspected clinically 3, 2
• Do not use buccal glucose as first-line treatment - it is less effective than swallowed glucose in conscious patients and inappropriate for unconscious patients 2
• Do not attempt oral glucose in patients who cannot safely swallow 3, 2, 4
• Do not use complex carbohydrates alone if patient takes α-glucosidase inhibitors 1
• Do not wait more than 15 minutes before re-treating if hypoglycemia persists 3, 1

Glucagon Administration Details (When IV Access Unavailable)

Dosing: 4, 5

• Adults and children >25 kg or ≥6 years: 1 mg (1 mL) IM/SC
• Children <25 kg or <6 years: 0.5 mg (0.5 mL) IM/SC
• Alternative dosing: 30 mcg/kg SC (maximum 1 mg) 4

Expected response:

• Glucagon increases blood glucose within 5-15 minutes 4
• If no response after 15 minutes, may repeat dose while waiting for emergency assistance 5
• Common side effects: nausea and vomiting, particularly with higher doses 4

Post-Stabilization Management

Before discharge, ensure:

• Medication regimen is reviewed and adjusted to prevent recurrence 1
• Patient and caregivers are educated on recognizing early hypoglycemia symptoms 2
• Glucagon is prescribed for home use with caregiver training on administration 1, 2
• Patient advised to carry fast-acting glucose sources at all times 1, 2
• Medical identification indicating diabetes and hypoglycemia risk is recommended 2

For patients with hypoglycemia unawareness:

• Raise glycemic targets for at least several weeks to reverse unawareness and reduce future risk 1
• Implement strict avoidance of any hypoglycemia during this period 1