Hypoglycaemia

Hypoglycaemia is a blood glucose level of below 4 mmol/l.

4 is the floor

Hypoglycaemia

Mags BannisterDiabetes Nurse Consultant

What happens now in clinical practice re hypo’s?

Mild Hypoglycaemia

Sweating Dizziness Trembling Tingling hands,feet,lips or tongue Hunger Blurred vision Difficulty in concentration Palpitations Occasional headaches

Causes of hypoglycaemia

• Too much insulin/sulphonylurea • Extra activity e.g. shopping, DIY, gardening, sexual

activity or sport • Insufficient food (particularly CHO’s)• Delayed or missed meal • Poor injection technique/change of site • Change of routine • Alcohol• Heat - hot weather/sauna/hot bath

Autonomic Neuroglycopenic Malaise

Sweating

PalpitationsShakingHunger

Confusion

Drowsiness

Speech difficulty

In coordination

Atypical behaviour

Diplopia (double vision)

Nausea

Headache

Mild Neuroglycopenia

Cognitive dysfunction

Sweating

Tremor

Palpitations

Blurred vision

Aggression

Staggering

Autonomic activation

Severe NeuroglycopeniaSevere Neuroglycopenia

Release of counter Regulation Hormones

Blood glucose level

Unconsciousness/Coma

Death

Mild “hypo” - treatment• 6-7 Dextrose tablets• Glucochek• 6 sugar lumps• 4 teaspoons of sugar• 100mls Lucozade

15 - 20 grams rapid acting CHO

• Eat next meal if due

OR

• Have a snack, e.g. banana/bread /biscuits

etc

Ref The hospital management of hypoglycaemia in adults with diabetes mellitus 2010

SEVERE HYPOGLYCAMIARequires third party assistance

•Odd behaviour e.g. rudeness/laughter (appear to be drunk when not)•Aggressive behaviour•Confusion•UNCONSCIOUS

Severe hypo glycaemia• Take immediate action• Glucose in liquid form• LUCOZADE min 100mls• lemonade/cola/ribena-

200mls

• EAT NEXT MEAL if due

• OR

• TAKE A SNACK

If unable to take anything orally• 999• Give GLUCAGON

injection - I.M (can take 15mins to take effect)

OR• I.V. Dextrose 150mls 10% or 75mls 20%If necessary repeat

Ref The hospital management of hypoglycaemia in adults with diabetes mellitus 2010

• Re-check blood glucose in 10 minutes after IV glucose if still below 4mmols repeat

• When blood glucose above 4.0mmls give long acting carbohydrate

• Monitor blood glucose levels

Which Patients with Diabetes are at Risk of Hypoglycaemia

TYPE 1

ALL

Type 2• If treated with a

sulphonyurea ( gliclazide or glimepiride)

• If treated with Insulin• If treated with a

combination that includes either or both or the above

PreventionPrevention

• Ensure Staff understand the mode of action of the treatment prescribed

• Discuss timing & dose of oral therapy/insulin

• Educate Staff how to prevent/recognise hypo symptoms

Prevention• Ensure patients are aware of the

correct/safe treatment of hypos

• Discuss the acceptable blood glucose levels for the individual patients needs

• Maintain good glycaemia control without compromising patient safety

Hyperglycaemia and illness management

High Blood glucose levels

What blood glucose levels cause concern?

What would you do if a patients blood glucose levels were running high?

Illness

• Infection• Steroids• Stress

• High Blood glucose levels

• Poor appetite• Poor fluid intake

Steroid treatment

• Fasting blood glucose levels will often be within normal range 5-10mmols/l

• Pre-tea and bed time readings can be >20mmols/l

• Blood glucose levels rapidly increase • Insulin maybe need when on steroid

treatment but not at any other time

DIABETIC KETOACIDOSISType 1 DM

A state of severe, uncontrolled diabetes due to insulin deficiency and increased counter regulatory hormones.

• High blood glucose levels (PG>11 mmol/l• Moderate ketonuria (3mmol/L or over 2+on urine

stick)• Acidosis (arterial pH<7.30 & serum bicarb<

15mmol/L.)• Usually Type 1

Ref: The management of Diabetic Ketoacidosis in adults NHS Diabetes 2010

DKA

Reduced glucose uptakeIncreased liver glucose output

Hyperglycaemia

Glycosuria

Breakdown of fat

Ketosis

Lack of insulin

Loss of water, change in electrolytes

Dehydration

Tachycardia, hypotension

Electrolyte imbalance, acidosis

Impaired consciousness, coma

Reduced pH, vomiting, ketonuria, hyperventilationOsmotic diuresis

Hyperosmolar Hyperglycaemic StateHHS

Type 2 DM

• Severe hyperglycaemia (PG>33.3 mmol/L)• Profound dehydration (-10L)• No ketosis/acidosis (pH>7.3)• Middle-aged/elderly• Insidious onset (days/weeks)• Often undiagnosed Type 2• Mortality 15- 20%

HHS

Reduced glucose uptakeIncreased liver glucose output

Hyperglycaemia

Glycosuria

Lack of insulin

Loss of water, change in electrolytes

Dehydration

Tachycardia, hypotension

Osmotic diuresis

HYPERGLYCAEMIA – Sick Day Rules

• Never stop taking insulin or tablets (metformin and SGLT2i should be omitted if dehydration a risk)

• Monitor more often• Type 1 – test Urine or Blood for ketones• Encourage more Fluids (sugar free)• Rest• Vomiting – if accompanied by rapid deep

breathing + drowsiness – dial 999• If BG persistently raised – insulin dose may be

increased temporarily

If unable to eat - replace solid food with alternatives such as

Alternative Amount CHO content

Soup (thickened or creamed) 200mls 15grams

Milk 200mls 10 grams

Pure fruit juice 100mls 10 grams

Lucozade 60mls 10 grams

Build up/ Complan 1/3rd serving 10 grams

Milk pudding /Custard 75g or ½ pot 10 grams

Accessing AdviceDiabetes Specialist Nursing team

Horton Park CentreMonday to Friday

01274 3237288.30-12.30 and 1.30-5.30

Emergency on call Monday to Friday

7.30-8.30am and 5.30pm- 9pmSaturday and Sunday and Bank Holidays

7.30am -9pm01274 494194

Information needed when ringing DSN

• Patients name , DOB and NHS number• Current treatment• Type of diabetes• Blood glucose levels• Ketones level if indicated• Any signs of illness/infection

Questions