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Hypoglycemia

Hypoglycemia. Wor kshop Hypoglycaemia and its management. Dubai February 2014. Hypoglycaemia. Formal definition Blood glucose <70-mg/dl Causes Too much insulin? Too little food? Unusual exercise? FOUR IS THE FLOOR.

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Hypoglycemia

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  1. Hypoglycemia Workshop Hypoglycaemia and its management Dubai February 2014

  2. Hypoglycaemia • Formal definition • Blood glucose <70-mg/dl • Causes • Too much insulin? • Too little food? • Unusual exercise? • FOUR IS THE FLOOR

  3. WHICH PATIENTS WITH HYPOGLYCAEMIA SHOULD BE ADMITTED TO HOSPITAL FROM A & E FOLLOWING HYPOGLYCAEMIC COMA? • Insulin treated patients who recover quickly from hypoglycaemic coma and who are otherwise well and able to eat normally may not need to be admitted to hospital. Admission is advised for: • Any insulin treated patient who is slow to recover • Large amounts of insulin injected in error or with suicidal intent • Insulin treated patients who are drunk - alcohol may precipitate or prolong hypoglycaemia • Insulin treated patients with hypopituitarism, hypoadrenalism or chronic renal failure • Elderly patients on sulfonylureas

  4. Adrenergic symptoms Tachycardia Palpitations Tremor Anxiety Sweating Flight or fright symptoms Neuroglycopenia Faintness Feeling of hunger Headache Abnormal behaviour Altered consciousness Eventually, coma Lack of glucose to brain Clinical features of hypoglycaemia

  5. Hypoglycemia unawareness Autonomic: tremor, sweating, hunger, heart palpitations,anxiety. Neuroglycopenic: confusion, difficulty concentrating, blurred vision, weakness, drowsiness, irritability.

  6. COUNTER-REGULATORY MECHANISM ACTIVATED BY HYPOGLYCAEMIA Glucagon release Fall in blood glucose Vagal stimulation Parasympathetic Stimulates glycogen breakdown in liver Adrenal medulla stimulation Sympathetic Neuroglycopenia Adrenaline release

  7. HYPOGLYCAEMIC COMA IN DIABETIC PATIENT IMMEDIATE MANAGEMENT Hypoglycaemic reaction (‘hypo’) in a diabetic patient on insulin can result from excessive insulin dosage, excessive exercise or decreased carbohydrate intake due to missed or delayed meal. It can also occur in elderly patients due to sulfonylurea therapy • Patient’s skin feels moist and sweaty • Reflexes may be brisk with extensor plantar response • Confirm with plasma glucose <3 mmol/L Diagnosis • If conscious, sugar or sweet drinks e.g. 75g glucose or 250mls lucozade • If drowsy, HYPOSTOP gel • If unconscious: Treatment • Glucagon* 1mg i.v., i.m. or s.c. • Restores consciousness in 10-15 mins • 20ml 50% dextrose i.v. • Restores consciousness within 5 mins and/or Severe hypoglyceamia with no response to glucagon or dextrose - ? cerebral oedema • high dose steroids e.g. 2 mg dexamethasone i.v. 4-6 hourly • 200ml 20% mannitol over 20-30 mins • high flow oxygen • dextrose infusion 10% or 20%, 0.5 litre 2-4 hourly • consider ITU for ventilation * If hypoglycaemia is precipitated or associated with excess alcohol intake, glucagon may be ineffective as alcohol blocks glycogenolytic action of glucagon

  8. Hypoglycaemia: Treatment

  9. Insulin Diet Exercise Diabetes Equilibrium

  10. Sulphonylurea induced hypoglycaemia • Sulphonylureas cause release of insulin from the pancreatic  cells • Continued production of insulin without adequate carbohydrate HYPOGLYCAEMIA • Check blood glucose to confirm hypoglycaemia • Treatment iv dextrose • May need prolonged infusion

  11. Glucose-lowering agents classified by risk of hypoglycaemia in type 2 diabetes Hypoglycemia 1. Nathan DM, et al. Diabetologia. 2009;52:17-306. 2. Cefalu WT. Nature. 2007;81:636-49.

  12. UK Hypoglycaemia Group Study: Frequency of Severe Hypoglycemia Type 2 DM Sulfonylureas (n = 103) Type 2 DM <2 years insulin (85) Type 2 DM >5 years insulin (75) Type 1 DM <5 years (46) Type 1 DM >15 years (54) 50 40 30 20 10 0 Annual prevalence of severe hypoglycemia (%) (Severe: requiring external assistance) T2DM SU T2DM < 2 yrs T2DM > 5 yrs T1DM < 5 yrs T1DM > 15 yrs Error bars = 95% confidence intervals Adapted from: UK Hypoglycaemia Study Group (2007)Diabetologia; 50: 1140

  13. Holstein A et al. Exper Opin Drug Saf 2010

  14. Holstein A et al. Exper Opin Drug Saf 2010

  15. Holstein A et al. Exper Opin Drug Saf 2010

  16. Morbidity of Hypoglycaemia in Diabetes Brain Blackouts, seizures, coma Cognitive dysfunction Psychological effects Cardiovascular Myocardial ischaemia (angina and infarction) Cardiac arrhythmias Musculoskeletal Falls, accidents (& driving accidents) Fractures, dislocations

  17. Outcomes of Hypoglycaemia DeSouza CV, et al. Diabetes Care 2010; 33: 1389.

  18. Cardiac function during hypoglycaemia Fisher et al (1987) Diabetologia; 30: 841 Hilsted et al (1984) Diabetologia; 26: 328

  19. OTHER POINTS TO NOTE RE PATIENTS WITH HYPOGLYCAEMIC COMA • Hypoglycaemia may cause hypothermia • Hypoglycaemic fitting can cause vertebral and occasionally long bone fractures • Watch for ‘delayed’ hypoglycaemia due to excessive exercise

  20. KEY TEACHING POINTS • Always consider hypoglycaemia in any person whose behaviour or conscious level is abnormal. • Hypoglycaemia can present with fitting. • Even close colleagues may not be aware that the patient is on insulin. • Neurological signs will disappear quickly with correction of hypoglycaemia. • Prolonged hypoglycaemic coma can cause irreversible neurological damage.

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