Morning Report

Morning Report: 2/3/2015

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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

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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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
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1 comment for “Morning Report: 2/3/2015”

  1. 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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