inpatient / endocrinology
Hypoglycemia
# Hypoglycemia
Assessment:
-- History: *** diabetes, meds and adherence, nutrition and PO intake, weight loss, emesis, CKD
-- Clinical/Exam: *** diaphoresis, visual changes, headaches, AMS, seizure, coma
-- Data: *** insulin level, c-peptide level, beta-hydroxybutyrate, pro-insulin, sulfonylurea and meglitinide screen
-- Etiology/DDx: *** Insulin Mediated: insulin or sulfonylurea overdose or exogenous administration, insulinoma (endogenous), autoimmune insulin antibodies; Non-Insulin Mediated: malnutrition, chronic EtOH use, ESRD, cirrhosis, sepsis, adrenal insufficiency
Plan:
Workup
-- (drawn while hypoglycemic) - insulin level, c-peptide level, beta-hydroxy butyrate, pro-insulin, sulfonylurea and meglitinide screen
-- If c/f insulinoma - will do PET scan to localize the tumor
Treatment
-- PRN 15g PO dextrose gel > IV 12.5-25g D50
-- IV D5LR drip if needed
PDF coming soon!
If You Remember Nothing Else
Severe hypoglycemia can be life threatening, always check a level if a patient is altered. Differentiate between insulin mediated and non-insulin mediated etiologies. Make sure your workup is sent when the patient is actually hypogylcemic (if insulin is normal-high despite being hypoglycemic, indicates an inappropriate release). Avoid iatrogenic hypogylcemia int he hospital by reducing the home dose of insulin, especiall ythe long-acting dose when patients are NPO.
Clinical Pearls
- Hypoglycemia is usually defined by glucose <70, but most patients will start to have clinically significant (symptomatic) hypoglycemia at levels <50
- Whipple’s Triad - symptoms of low glucose, proven low blood glucose while having symptoms, resolution of symptoms with glucose correction
- If the hypoglycemia is insulin-mediated, there will be no ketones present
- C-peptide is cleaved from pro-insulin that is made in the body - will be high when insulin is made endogenously and not present when exogenous
- Can see pseudo-hypoglycemia from peripheral vasoconstriction (finger stick), delayed sample processing, and leuko/erythrocytosis
- Usually have symptoms (but are not a chronically sick person) when the hypoglycemia is insulin-mediated since insulin works fast and is not 2/2 anorexia, liver/kidney disease, sepsis, cancer, adrenal insufficiency, etc.
Trials and Literature
- The Risk Factors of Inpatient Hypoglycemia (Review) (Heliyon, 2020)
Other Resources
- Inpatient Management of Diabetes Template
- Curbsiders Podcast - Episode #126
- Clinical Problem Solvers - Dx Schema for Hypoglycemia
