Diabetes Summary (Hypoglycemia)

Scenario A
A. Adults who are conscious, orientated and able to swallow.
  1. Give 15-20g quick acting carbohydrate of the patient's choice where possible. Some examples are:
    • 150-200 ml pure fruit juice e.g. orange
    • 5-7 Dextrosol® tablets (or 4-5 Glucotabs®)
    • 1 bottle of Glucojuice®
    • 3-4 heaped teaspoons of sugar dissolved in water
    • Repeat capillary blood glucose measurement 10-15 minutes later. If it is still less than 4.0mmol/L, repeat step 1 up to 3 times
    • If blood glucose remains less than 4.0mmol/L after 45 minutes or 3 cycles, contact a doctor. Consider 1mg of glucagon IM (may be less effective in patients prescribed sulphonylurea therapy) or 150-200mL IV 10% glucose infusion over 15 minutes. Volume should be determined by clinical circumstances (refer to Appendix 4 for administration details).
    • Once blood glucose is above 4.0mmol/L and the patient has recovered, give a long acting carbohydrate of the patient's choice where possible, taking into consideration any specific dietary requirements. Some examples are:
      • Two biscuits
      • One slice of bread/toast
      • 200-300ml glass of milk (not soya)
      • Normal meal if due (must contain carbohydrate)
      DO NOT omit insulin injection if due (However, dose review may be required). N.B. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen stores (double the suggested amount above).
    • Document event in patient's notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged. Give hypoglycaemia education or refer to diabetes inpatient specialist nurse (DISN).
Scenario B
B. Adults who are conscious but confused, disorientated, unable to cooperate, aggressive but are able to swallow.
  1. If the patient is capable and cooperative, follow section A in its entirety.
  2. If the patient is not capable and/or uncooperative, but is able to swallow give either 1.5 -2 tubes GlucoGel 40%; squeezed into the mouth between the teeth and gums or (if this is ineffective) give glucagon 1mg IM (may be less effective in patients prescribed sulphonylurea therapy).
  3. Repeat capillary blood glucose levels after 10-15 minutes. If it is still less than 4.0mmol/L repeat steps 1 and/or 2 (up to 3 times).
  4. If blood glucose level remains less than 4.0mmol/L after 30-45 minutes (or 3 cycles of A1), contact a doctor. Consider 150-200mL IV 10% glucose infusion over 15 minutes. Volume should be determined by clinical circumstances (refer to Appendix 4 for administration details)
  5. Once blood glucose is above 4.0mmol/L and the patient has recovered, give a long acting carbohydrate of the patient's choice where possible, taking into consideration any specific dietary requirements. Some examples are:
    • Two biscuits
    • One slice of bread/toast
    • 200-300ml glass of milk (not soya)
    • Normal meal if due (must contain carbohydrate)
    DO NOT omit insulin injection if due (However, dose review may be required)

    N.B. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen stores (double the suggested amount above).
  6. Document event in patient's notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged. Give hypoglycaemia education or refer to DISN.
Scenario C
C. Adults who are unconscious and/or having seizures and/or are very aggressive.
  1. Check:
    • Airway (and give oxygen)
    • Breathing
    • Circulation
    • Disability (including GCS and blood glucose)
    • Exposure (including temperature)
    If the patient has an insulin infusion in situ, stop immediately. Fast bleep a doctor
  2. The following three options (i-iii) are all appropriate; local agreement should be sought:
    • Glucagon 1mg IM (may be less effective in patients prescribed sulphonylurea therapy). Glucagon, which may take up to 15 minutes to take effect, mobilises glycogen from the liver and will be less effective in those who are chronically malnourished (e.g. alcoholics), or in patients who have had a prolonged period of starvation and have depleted glycogen stores or in those with severe liver disease. In this situation or if prolonged treatment is required, IV glucose is better.
    • If IV access available, give 75-100ml of 20% glucose (over 10-15 minutes). (Preparation is a ready to use 100ml small volume infusion that will deliver the required amount after being runthrough a standard giving set). If an infusion pump is available use this, but if not readily available the infusion should not be delayed (see Appendix 4 for administration details). Repeat capillary blood glucose measurement 10 minutes later. If it is still less than 4.0mmol/L, repeat.
    • If IV access available, give 150-200ml of 10% glucose (over 10-15 minutes). If an infusion pump is available use this, but if not readily available the infusion should not be delayed. Repeat capillary blood glucose measurement 10 minutes later. If it is still less than 4.0mmol/L, repeat (refer to Appendix 4 for administration details).
  3. Once the blood glucose is greater than 4.0mmol/L and the patient has recovered give a long acting carbohydrate of the patient's choice where possible, taking into consideration any specific dietary requirements. Some examples are:
    • Two biscuits
    • One slice of bread/toast
    • 200-300 ml glass of milk (not soya)
    • Normal meal if due (must contain carbohydrate)
    DO NOT omit insulin injection if due (However, dose review may be required). N.B. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen stores (double the suggested amount above). If the patient was on IV insulin, continue to check blood glucose every 30 minutes until above 3.5mmol/L, then re-start IV insulin after review of dose regimen.
  4. Document event in patient's notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged. Give hypoglycaemia education or refer to DISN.
N.B. Patients who self manage their insulin pumps may not need a long acting carbohydrate.

Further detail/information is available from the ‘Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus’ guideline from the Joint British Diabetes Societies for Inpatient Care. Available from: https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/2018-05/JBDS_HypoGuidelineRevised2.pdf%2008.05.18.pdf
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