Dr. Lewis presents today’s Morning Report!

 

Hypoglycemia

Hypoglycemia: serum glucose of <50 mg/dL, less than 30 mg/dL is considered severe hypoglycemia

 

Causes

Re Renal

Ex Exogenous Insulin/antihyperglycemics

P Pituitary Insufficiency

L Liver

A Alcohol, Addison’s, Aspirin

I Infection, Insulinoma

N Neoplasm

D Drugs

 

Medications

Sulfonylureas (glipizide/glyburide): ↑insulin secretion and activity, half-life of most is 14-16 hrs

Meglitinides(prandin/starlix): shorter half-life, risk of recurrent hypoglycemia is unknown

Biguanides(metformin)→ enhance effect of insulin without increasing secretion

 

Symptoms

  • Early: Catecholamine release → Adrenergic = tachycardia, irritability, diaphoresis, paresthesias
  • More severe or prolonged hypoglycemia → Neuroglycopenia → ms changes including confusion or bizarre behavior, lethargy, or coma, focal neurologic deficits

 

Management

IV Glucose

  • Adults: 0.5 to 1 g/kg, 1 amp of D₅₀ = 50 cc of 50% dextrose in water = contains 25 g of glucose = 100 calories, lasts 15-30 mins, after 30 mins feed or D₁₀W
  • Child: D₂₅ 2 cc/kg, Neonate: D₁₀ 2-4 cc/kg
  • Caution: pts that can produce insulin via glucose-stimulated insulin release (nondiabetics or type 2 DM) repeated dextrose →recurrent hypoglycemia
  • 1 L D5W at 100mL/hr = 20 cal/hr (5 skittles/hr), 1 L D10W at 100mL/hr = 40 cal/hr (10 skittles/hr)

 

Glucagon

  • Stimulates cAMP →promotes hepatic glycogenolysis and gluconeogenesis
  • 1 mg subq or IM repeated q20 mins, requires ≥15 mins for onset of action, associated with vomiting
  • may be ineffective in pts with depleted glycogen stores, stimulates insulin release from the pancreas → prolonged hypoglycemia in settings such as sulfonylurea ingestion and insulinoma

 

Octreotide

  • Synthetic somatostatin = inhibit glucose-stimulated β cell insulin release, half-life of 72 minutes, duration 6-12 hrs, peaks at 20 mins
  • Sulfonylurea-induced hypoglycemia
  • IV/subq suggested dose is subq 50-100 µg q6hrs, IV 100-125 µg/hr after 2nd episode of hypoglycemia
  • Fewer episodes of recurrent hypoglycemia 

 

Special consideration

  • Pts with sulfonylurea/meglitinide related hypoglycemia after initial control with D₅₀→ feeding or octreotide, routine dextrose infusion should be avoided b/c it causes glucose stimulated insulin release

 

Disposition

  • Diabetic on therapeutic doses of insulin with hypoglycemia after missed meal /metformin→ d/c after 4-6 hr observation
  • All hypoglycemia related to sulfonylurea use/lantus → admit

 

References

Goldfrank’s Toxicologic Emergencies, 10eRobert S. Hoffman, Mary Ann Howland, Neal A. Lewin, Lewis S. Nelson, Lewis R. Goldfrank

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Jay Khadpe MD

  • Editor in Chief of "The Original Kings of County"
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

Latest posts by Jay Khadpe MD (see all)

Categories: Endocrinology

Jay Khadpe MD

  • Editor in Chief of “The Original Kings of County”
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

1 Comment

Ian deSouza · February 5, 2015 at 1:46 pm

Severe hyoglycemia (can be considered an “H” in the “Hs/Ts”) resulting in neuroglycopenia MAY lead to PEA arrest. It not a typical cause of cardiac arrest and it not often described in the literature, but I have seen one case where hypoglycemia was a likely culprit, only discovered after a post-intubation/resuscitation blood gas…..

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