Causes and Management of Hypoglycaemia

Definition of Hypoglycaemia:

When blood glucose level is below 3.5 mmol/ L then it is called hypoglycaemia. It occurs in a patient who is treated by insulin or sulphonylurea & not a manifestation of the disease itself.

Causes of Hypoglycemia:

It includes-

• Missed, delayed or inadequate meal,
• Unexpected or unusual exercise,
• Alcohol,
• Errors in oral hypoglycemic agent or insulin dose/schedule/administration,
• Poorly designed insulin regimen, particularly if predisposing to nocturnal hyperinsulinaemia,
• Lipohypertrophy at injection sites causing variable insulin absorption,
• Gastroparesis due to autonomic neuropathy,
• Mal-absorption, eg. celiac disease,
• Unrecognized other endocrine disorder, eg. Addison’s disease,
• Factitious (deliberately induced),
• Breastfeeding by diabetic mother.

Management of Hypoglycaemia:

Clinical features:

• Usually rapid onset,
• May be preceded by odd behavior (eg. aggression),
• Sweating, increase pulse, seizures.

Common symptoms of hypoglycemia:

Autonomic:

• Sweating,
• V Trembling,
• Pounding heart,
• Hunger,
• Anxiety.

Neuroglycopenic:

• Confusion,
• Drowsiness,
• Speech difficulty.

Inability to concentrate, Incoordination

Non-specific:

• Nausea,
• Headache,
• Tiredness

Investigation:

• Blood glucose: very low
• Urine examination: No glycosuria, no ketonuria

Treatment of Hypoglycemia:

• Give 50 ml 50% dextrose IV state. This harms veins, so follow by 0.9% saline flush. Expect prompt recovery.
• If not recovered, give dexamethasone 4 mg/4hour IV to combat cerebral oedema after prolonged hypoglycemia.
• A continuous IV infusion of dextrose (5% or 10%) may be necessary to prevent recurrent of hypoglycemia.
• If IV access fails try glucagon 1-2 mg.
• On regaining consciousness give sugary drinks.

Risk Factors of Severe Hypoglycemia:

It includes the following:

• Strict glycaemic control,
• Impaired awareness of hypoglycemia,
• Age (very young and elderly),
• Increasing duration of diabetes,
• Sleep,
• C-peptide negativity,
• History of previous hypoglycemia,
• Renal impairment,
• Angiotensin converting enzyme (ACE) genotype.

Difference Between Hypoglycemic Coma and Hyperglycemic Coma:

Point of Differences	Hypoglycemic Coma	Hyperglycemic Coma
History	· Missed meal, delayed meal · Excessive exercise · Insulin overdose · Mal-absorption	· Low dose of drug, · Digestive disturbance, · Stressful condition, · Intercurrnet infection.
Onset	In minutes	Over hours or days
Symptoms	Vomiting (occasionally)	Abdominal pain and vomiting
Signs	· Normal hydration most skin and tongue, · Marked sweating, · Breathing shallow or normal, · Pulse full, · Systolic BP normal or raised, · Brisk reflexes, Babinski +ve.	· Dehydrated — dry skin and tongnue, · Sweating absent, · Deep rapid breathing/Kussmaul breathing, · Pulse weak, · BP-Low, · Diminished reflexes.
Urine	No ketonuria	Ketonuria, glycosuria
Blood	· Hypoglycemia, normal plasma HCO3 · No hyperkitonaemia	· Hypoglycemia, reduced plasma HCO3 · Hyperkitonaemia
IV glucose	Good response	No response