How can I prescribe glucose for a Nil By Mouth (NBM) patient with hypoglycemia?

From the Guidelines

For a nil-by-mouth (NBM) patient with hypoglycemia at 3.5 mmol/L, I recommend administering intravenous (IV) dextrose as the most effective treatment option. According to the 2024 American Heart Association and American Red Cross guidelines for first aid 1, untreated hypoglycemia can cause seizures, status epilepticus, permanent brain injury, and death, making prompt treatment crucial.

Key Considerations

• The guidelines suggest that for people with hypoglycemia who are unable to swallow, intravenous dextrose can be lifesaving 1.
• Oral glucose administration is effective for patients who can swallow, but for NBM patients, IV dextrose is the preferred route.
• The initial treatment should be 100-150 mL of 10% dextrose (D10W) given as an IV bolus, with alternative options being 50 mL of 20% dextrose or 25 mL of 50% dextrose if 10% dextrose is unavailable.

Ongoing Management

• After administering the initial bolus, it's essential to recheck the blood glucose level in 15-30 minutes to ensure it has normalized.
• For ongoing management, consider starting an IV infusion of 5% or 10% dextrose at a rate of 100-125 mL/hour until the patient can resume oral intake or the underlying cause of hypoglycemia is addressed.

Underlying Cause

• Investigating and treating the underlying cause of hypoglycemia is crucial while providing glucose supplementation.
• Dextrose is rapidly metabolized in the body and converted to glucose, which raises blood glucose levels quickly to prevent neurological symptoms and complications of hypoglycemia.

From the FDA Drug Label

For peripheral vein administration: Injection of the solution should be made slowly. The maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg of body weight/hour. About 95% of the dextrose is retained when infused at a rate of 0. 8 g/kg/hr. In insulin-induced hypoglycemia, intravenous injection of 10 to 25 grams of dextrose (20 to 50 mL of 50% dextrose) is usually adequate. To prescribe glucose for a NBM (nothing by mouth) patient who is hypoglycemic at 3.5mmol, you can administer 10 to 25 grams of dextrose intravenously, which is usually adequate for insulin-induced hypoglycemia. The dose can be given as 20 to 50 mL of 50% dextrose. It is essential to administer the dextrose promptly without awaiting pretreatment test results.

• Key considerations:
  • Administer the solution slowly.
  • The maximum rate of dextrose administration should not exceed 0.5 g/kg of body weight/hour to avoid glycosuria.
  • Monitor the patient's condition and adjust the dosage as needed.
  • Repeated doses and supportive treatment may be required in severe cases. 2

From the Research

Treatment Options for Hypoglycemia in NBM Patients

• For a patient who is Nothing By Mouth (NBM) and experiencing hypoglycemia at 3.5mmol, intravenous dextrose is a common treatment option 3, 4, 5, 6.
• The choice of dextrose concentration, such as 10% (D10) or 50% (D50), depends on the severity of hypoglycemia and the patient's response to treatment 3.
• D10 may be as effective as D50 in resolving symptoms and correcting hypoglycemia, although the desired effect may take several minutes longer 3.
• Intramuscular glucagon is also a viable alternative to intravenous dextrose, especially in situations where intravenous access is not available 4, 5, 6.

Comparison of Treatment Outcomes

• Studies have shown that intravenous dextrose can lead to faster recovery times compared to intramuscular glucagon 4, 5, 6.
• However, intramuscular glucagon may result in a more stable glycemic profile and fewer adverse events 4, 5, 6.
• The choice of treatment should be based on the individual patient's needs and the clinical context 3, 4, 5, 6.

Clinical Guidelines and Protocols

• The Hypoglycemia Protocol should be revised to include guidelines for the treatment of severe hypoglycemia in NBM patients 7.
• Intravenous dextrose may be more efficacious than oral carbohydrate treatment in patients with diabetes experiencing severe hypoglycemia 7.
• The protocol should include criteria for escalating treatment from oral to intravenous dextrose 7.