HYPOGLYCEMIA ALGORITHM

SOUTHERN PHILIPPINES MEDICAL CENTER

Department of Internal Medicine
Proposed by: Dr. Neil Carlo Ramos and Dr. Fatima Dhiena Julhan
Adviser: Dr. Suzette Alegarbes

Patient is:
Patient is:
• awake CBG < 80mg/dl • Unresponsive/Intubated
• responsive
• without risk of aspiration • With decrease in sensorium
• at risk of aspiration

Establish IV access:
PATIENT NOT ON NPO PATIENT ON NPO Give D50W as follows:
• 15cc IV for CBG <80 mg/dl
• 25cc IV for CBG <70 mg/dl
• 50cc IV for CBG <50 mg/dl
Give 15g of Glucose using:
Repeat CBG after 15mins
• 3 tsp of sugar + ½ glass water
• 150ml fruit juice or regular soda
• 1 tbsp of honey
Repeat CBG after 15mins

Is CBG now NO NO Is CBG now

> 100 mg/dl? > 100 mg/dl?

YES

YES
Instruct patient to take a
Repeat for 2 more takes with carbohydrate-containing Repeat for 2 more takes with
15-minute intervals snack or meal within 15-minute intervals
30minutes

PATIENT NOT ON NPO PATIENT ON NPO

Decrease CBG monitoring to

regular schedule

Resume feeding Maintain closer

monitoring of CBG
Evaluate Cause of every 4 hours
hypoglycemia and educate
patient for future prevention ONCE FEEDING IS RESUMED

SIGNS/SYMPTOMS OF HYPOGLYCEMIA WHAT NOT TO DO IN HYPOGLYCEMIA PREVENTION STRATEGIES

Adrenergic Symptoms Neuroglycopenic Signs • Recognizing precipitating factors

• Feed conscious patients milk or
• Pallor • Confusion • Ordering appropriate scheduled
chocolates (complex
• Diaphoresis • Slurred Speech insulin or anti-diabetic oral agents
carbohydrates)
• Tachycardia • Irrational Behavior • Monitoring blood glucose at
• Automatically give patients 2
• Shakiness • Disorientation bedside
• Syncope vials of D50W
• Hunger • Patient, family and staff education
• Avoid fruit juices for renal
• Anxiety • Seizures • Applying systems for eliminating or
patients
• Dizziness • Sluggish Pupils reducing medication and treatment
• Feed patients without checking
subsequent CBG errors

“HYPOGLYCEMIA NOT CORRECTED PROPERLY CAN BE AS JUST AS DEADLY HYPOGLYCEMIA ITSELF”

Tomky, D. (2005). Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum, 18(1), 39–44.
Hypoglycemia. (2013). Canadian Journal of Diabetes, 37, S314. https://doi.org/10.1016/j.jcjd.2013.02.013
 HYPOGLYCEMIA ALGORITHM
SOUTHERN PHILIPPINES MEDICAL CENTER
Department of Internal Medicine
Proposed by: Dr. Neil Carlo Ramos and Dr. Fatima Dhiena Julhan
Adviser: Dr. Suzette Alegarbes

HOW DO WE DEFINE HYPOGLYCEMIA? WHAT IS THE RATIONALE OF PROPER CORRECTION

OF HYPOGLYCEMIA?
• No universal value is recognized, but a CBG of less than or
equal to 80mg/dl can already be considered hypoglycemia. • Current protocols employed are based on the
recommendation of correcting hypoglycaemia slowly
WHAT ARE THE SIGNS & SYMPTOMS OF HYPOGLYCEMIA? but correctly with 15-20 grams with a monosaccharide
such as glucose, and then rechecking for an increase in
• Signs and Symptoms happen as a consequence of the the CBG after 15 minutes.
bodies compensatory response to decreasing blood sugar • This rate of correction allows for effective correction,
levels. These vary and may occur at different severities of without the risk of overcorrection of hypoglycaemia,
hypoglycemia. These include: which might lead to complications such as rebound
• Pallor • Slurred Speech hyperglycemia, hyperosmolar syndrome, hypokalemia.
• Diaphoresis • Irrational behavior
• Tachycardia • Extreme fatigue WHAT ARE THE COMMON MISTAKES IN CORRECTING
• Shakiness • Disorientation HYPOGLYCEMIA?
• Hunger • Loss of consciousness
• Anxiety • Seizures • FEEDING THE PATIENT MILK/CHOCOLATES – These are
• Irritability • Pupillary sluggishness complex carbohydrates which still take time to be broken
• Headache • Decrease response to down into the simple sugars which are better absorbed by
• Dizziness noxious stimuli the gastrointestinal tract. Use of these products lead to a
• Confusion delay in correction of hypoglycaemia, and will also lead to
a later increase in the blood sugar levels once they are
fully broken down. A common reflex reaction to inpatients
HOW DO WE PREVENT HYPOGLYCEMIA IN OUR PATIENTS?
are allowing them to be fed or to drink milk, especially
• PATIENT EDUCATION – Patient involvement will promote with patients on NGT feeding. These should be corrected
better compliance to medications and increase awareness • KNEE-JERK REACTION TO GIVE FULL VIALS OF D50W – As
to the early signs and risk factors for hypoglycaemia. mentioned, correction of hypoglycaemia should depend
Moreover, family and hospital staff education and on the noted CBG levels, indicating a specific volume of
involvement can further aid in preventing hypoglycemia D50W per CBG level. This is to avoid overcorrection. Also,
• DIETARY INTERVENTION – Appropriate nutrition is in patients who are awake and able to feed, an oral route
paramount for patients at risk of hypoglycaemia, even the of administering carbohydrates is still the more effective
non-diabetic ones. A carbohydrate diet which matches a way of treating hypoglycaemia.
patient’s insulin regimen is important. All meals should be • LACK OF GOOD CBG FOLLOW-UP AFTER CORRECTION –
composed of carbohydrates should also be in balance with Even though D50W or feeding has been started in a
protein, fat, and fiber. hypoglycemic patient. Monitoring response after 15
• GLUCOSE MONITORING – Bedside monitoring of CBG minutes should not be neglected as not all immediate
should be performed at least four times daily (before feeding/D50W supplementation elicit an adequate
meals and at bedtime for patients who are eating. Patient increase in CBG trends, and as such, complications may
who are on NPO or require continuous tube feeding should still occur.
have CBGs checked at least every 6 hours. In circumstances
of unusual tube-feeding schedule, timing of CBG
monitoring should also be coincided with the timing of WE RECOMMEND EACH NURSE STATION TO HAVE IN STORE A
feedings “HYPOGLYCEMIA PACK” FOR IMMEDIATE MANAGEMENT OF
• MEDICATION ADJUSTMENT – Prompt and strict ACUTELY HYPOGLYCEMIC PATIENTS, COMPOSING OF THE
adjustments of Insulin regimen, and knowing when to use FOLLOWING:
and discontinue OHAs should be
• White sugar packets x 9pcs • CBG strips x 10 pcs
• RECOGNIZING TRIGGERING EVENTS – These include delays
• Bottled water 250ml x 3pcs • CBG monitor
in timing of meals or dosages of OHAs or insulin.
• Regular Soda x 3 small cans • IV cannulas x 3pcs
Comorbidities such as renal, adrenal, and pituitary
• Honey 1 tbsp packets x 3 pcs • Macroset x 3pcs
insufficiencies can also increase the risk of hypoglycaemia.
• D50W 50cc vials x 3 pcs • Alcohol swab
Knowledge of these risk factors should heighten awareness
• Disposable cups x 3pcs • Plaster
of staff and the patient himself/herself to be more
stringent in the precautions to prevent hypoglycaemia.

Tomky, D. (2005). Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum, 18(1), 39–44.
Hypoglycemia. (2013). Canadian Journal of Diabetes, 37, S314. https://doi.org/10.1016/j.jcjd.2013.02.013