Hypoglycemia & Hyperglycemia

1. Hypoglycemia & Hyperglycemia Dave Joffe, BSPharm, CDE, FACA Part 4

2. Hypoglycemia- in the hospital • May be associated with specific conditions in hospitalized patient populations: • Renal failure • Heart failure • Infection • Sepsis • Decrease in glucocorticoid use • Decreased oral intake or alteration in enteral or parenteral nutrition Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591. Campbell KB, Braithwaite SS. Hospital Management of Hyperglycemia. Clinical Diabetes. 2004;22:81-88.

3. Hypoglycemia Prevention • Frequent blood glucose monitoring • Glucose levels should be monitored hourly until levels are stable • After stabilization of glucose levels, monitoring may be performed every 2-4 hours • Adjustment of prandial insulin doses to account for alterations in oral intake • Adjustment of basal and prandial insulin TDD during high dose glucocorticoid administration: 30% basal insulin and 70% prandial insulin Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591 Campbell KB, Braithwaite SS. Hospital Management of Hyperglycemia. Clinical Diabetes. 2004;22:81-88

4. Hypoglycemia • Patients Responsive: Administer oral carbohydrate. Recheck blood glucose in 15 minutes and if blood glucose > 70 administer meal 30 minutes after. • Patient NPO Responsive: Either establish IV access and administer 10-20g of 50% DextroseOR administer 1g Glucagon IM. Recheck blood glucose every 15 minutes and administer carbohydrate again (PO or IV)if blood glucose is not greater then 70mg/dL. • Patient Nonresponsive: Establish IV access and administer 25g of 50% Dextrose OR administer 1g Glucagon IM. Check glucose in 15 minutes and if not > 70mg/dL then follow physicians orders.

5. Insulin Disaster • Patient initiated on feeding tube at noon and her blood glucose was 418 • Normal dose of insulin and at 2 pm her blood glucose was 453 • Physician ordered 10 units of regular insulin to be given IV • The nurse gave the 10 mL quantity of insulin to the patient, therefore giving 1,000 units of insulin at 3 pm

6. Insulin Disaster • By 5:55 pm, the patients blood sugar was 102 and oxygen + tube feeding continued • At 8:55 pm, blood glucose 78 and at 9:25 pm blood glucose 87 • By 9:30 pm, the patient did not have an audible heart rate and was not breathing • The patient died at 9:45 pm despite CPR

7. Prevention of Error • Develop a facility plan on how to treat hypoglycemia and insulin overdose based on amount of insulin given • Education of staff on proper administration and potency of insulin • Recognize different measurements and create standardization of ordering by using only one measurement, i.e. “units”

8. Hyperglycemia: Pathophysiology • Abnormal utilization of glucose in the body • Resistance in tissues • Not enough insulin present to get glucose into the cell • Continuously high levels of glucose in the body lead to macrovascular & microvascular complications • Excess glucose begins to spill over into urine • When the brain is not able to utilize the glucose it begins converting fats into an energy source it can use • Produces ketones • Ketoacidosis is the buildup of ketones in the blood which can cause shortness of breath, nausea, vomiting, and very dry mouth.

9. Hyperglycemia: The Values • Consistent levels >126 mg/dl indicate chronic hyperglycemia • Patients educated to seek medical attention if glucose values are persistently above 240 mg/dl

10. Hyperglycemia: The Causes • Diabetes Mellitus (most common cause) • Critical illness • Physical trauma, surgery, MI, stroke, ect. • Physiological Stress • Presence of infection or inflammation • Via endogenous catecholamines