What is the acute management of hypoglycemia (low blood sugar) in a patient?

Acute Management of Hypoglycemia

Immediate Treatment for Conscious Patients

For conscious patients with hypoglycemia (blood glucose ≤70 mg/dL), immediately administer 15-20 grams of oral glucose, recheck blood glucose in 15 minutes, and repeat the dose if hypoglycemia persists. 1, 2

First-Line Treatment Protocol

• Pure glucose is the preferred treatment because it produces a faster and more predictable glycemic response than other carbohydrate sources 3, 2
• Glucose tablets or glucose solution are most effective, though any carbohydrate containing glucose will work 3, 2
• Expect initial symptom relief within 10-20 minutes of treatment 3, 1
• Recheck blood glucose at 15 minutes—if still below 70 mg/dL, repeat another 15-20 gram dose 1, 2
• Recheck again at 60 minutes as additional treatment may be necessary 3, 1

Critical Treatment Pitfalls to Avoid

• Never add protein to carbohydrate treatment—protein may increase insulin secretion without raising glucose and does not prevent subsequent hypoglycemia 2, 4
• Avoid adding fat to treatment carbohydrates—fat slows and prolongs the glycemic response, delaying recovery 2, 4
• Orange juice and glucose gel are less effective than glucose tablets or solution for rapid symptom relief 3, 2

Immediate Treatment for Unconscious or Severely Altered Patients

For patients with severe hypoglycemia who are unconscious, unable to swallow, or have altered mental status, immediately administer 10-20 grams of intravenous 50% dextrose, stop any insulin infusion, and recheck blood glucose in 15 minutes. 3, 1

IV Dextrose Protocol

• Administer 25 mL of 50% dextrose as a slow intravenous push 3
• This typically produces blood glucose increases of approximately 162 mg/dL at 5 minutes and 63.5 mg/dL at 15 minutes 1
• Titrate the dose based on the initial hypoglycemic value 1
• Recheck blood glucose after 15 minutes—if still below 70 mg/dL, repeat dextrose administration 1
• Continue monitoring every 15 minutes until blood glucose stabilizes above 70 mg/dL 1
• Avoid overcorrection that causes iatrogenic hyperglycemia 1

Glucagon Administration (When IV Access Unavailable)

• Glucagon can and should be administered by family members or caregivers—it is not limited to healthcare professionals 1, 2
• Administer 1 mg intramuscular glucagon into the upper arm, thigh, or buttocks for adults and children weighing >25 kg or ≥6 years 5, 2
• For children weighing <25 kg or <6 years, administer 0.5 mg 5
• Newer intranasal and ready-to-inject glucagon preparations are preferred due to ease of administration 2
• If no response after 15 minutes, repeat the dose while waiting for emergency assistance 5

Post-Recovery Oral Carbohydrates

• Once the patient regains consciousness and can safely swallow, immediately give 15-20 grams of fast-acting oral carbohydrates 1, 5
• Follow with a meal or long-acting carbohydrates to prevent recurrence 1, 5
• Never attempt oral glucose in an unconscious patient—this creates aspiration risk and is absolutely contraindicated 1

Target Blood Glucose After Treatment

• Achieve blood glucose greater than 70 mg/dL 1, 2
• For hospitalized critically ill patients, maintain target range of 140-180 mg/dL 1
• For noncritically ill hospitalized patients, target 100-180 mg/dL 1

Post-Event Management and Prevention

Any episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia mandates immediate reevaluation of the diabetes management plan. 1, 2

Medication Adjustments

• Consider deintensifying or switching diabetes medications, particularly insulin, sulfonylureas, or meglitinides 2
• For patients with hypoglycemia unawareness, raise glycemic targets to strictly avoid hypoglycemia for at least several weeks to partially reverse the condition 2
• In cases of unexplained or recurrent severe hypoglycemia, consider admission to a medical unit for observation and stabilization 1, 2

Patient and Caregiver Education

• Prescribe glucagon for home use and train family members on administration 1, 2
• Educate on high-risk situations: fasting for tests/procedures, delayed meals, intense exercise, alcohol consumption, and sleep 2, 4
• Advise patients to always carry fast-acting glucose sources 1
• Recommend medical identification indicating diabetes and hypoglycemia risk 1

Hospital and Institutional Protocols

• Implement a standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol 1, 2
• Ensure immediate access to glucose tablets or glucose-containing foods for both patients and staff 1, 2
• Train all staff who supervise at-risk patients in recognition, treatment, and appropriate referral 1, 2
• Document blood glucose before treatment whenever possible, but never delay treatment while waiting for confirmation 2

High-Risk Features Requiring Intensive Monitoring

• History of recurrent severe hypoglycemia or hypoglycemia unawareness 1
• Concurrent illness, sepsis, hepatic failure, or renal failure 1
• Recent reduction in corticosteroid dose 1
• Altered nutritional intake, new nothing-by-mouth status, or unexpected interruption of feedings 1