Page 300 - fbkCardioDiabetes_2017

276 Hypoglycemia How Critical it is?

BG 60-70 mg/dLand patient has NO symptoms and Conscious, Cooperative and Able to Swallow
Immediate Action/Treatment Repeat Follow-up Treatment
No treatment required if scheduled Repeat BG and re-treat q15 If more than 1 hr until next meal/snack,
mealtime is within 30 min and patient min until BG > 100 OR symp- also give 15 gms of carbohydrate*:
willing/able to eat. toms resolved • 3 graham crackers OR
• 6 saltine crackers OR
If mealtime is more than 30 min , give Add order to check BG at • 8 oz skim milk
15 Grams carbohydrate: 0200 one time • If more than 2 hrs until next meal/
• 4 oz juice or regular pop OR snack.
• 1 TBSP jelly or sugar OR also add protein:
• 3 glucose tablets OR 1/2 sandwich OR
• 1 tube Dextrose Gel 3 graham crackers with one TBSP peanut
butter
BG 70 mg/dLand patient has NO symptoms NO TREATMENT REQUIRED

discontinuation of oral agents in the absence of an Practice Points
alternate method for diabetes control. These patients The relationship between glycemic control and mor-
should instead be converted to a subcutaneous or IV tality demonstrates a U- shaped or J –shaped curve
insulin regimen during hospitalization. Management with increased risk of death at both extremes.
with insulin in these circumstances is safer and has
the added benefit of increased dosing flexibility when The association between hypoglycemia and mortality
caloric intake is erratic. 2 may be more specific to ‘spontaneous hypoglycemia’
as opposed to iatrogenic hypoglycemia, implying that
4.Glucose Monitoring hypoglycemia may be a biomarker for poor progno-
sis rather than atrue cause of mortality.
Bedside monitoring of capillary blood glucose should
be performed at least four times daily (i.e., before Current guidelines for inpatient glycemic control
meals and at bedtime for patients who are eating). recommend maintaining blood glucose values in
A glucose check at 3:00 a.m. can also be useful in the range of 140-180mg/dl(7.8-10mmol/l) for most
patients with fasting hyperglycemia . An elevated patients. Values <100mg/dl(5.6mmol/l) should be
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glucose level at that time could indicate insufficient avoided, and therapy needs to be revised when val-
nighttime insulin dosing, whereas a low glucose level ues are<70mg/dl(3.9mmol/l)
at that time may indicate an early peak in evening Hypoglycemia unawareness is common particularly
insulin or insufficient caloric intake at bedtime.
in ill and elderly hospitalized patients, often having
low glucose levels without symptoms. For pragmatic
5.Medical Nutrition therapy reasons treatment is necessary when glucose levels
A consistent carbohydrate diet is important to appro- are<70mg/dl(3.9mmol/l) with or with out symptoms.
priately match the insulin regimen or secretagogue Less intensive control is appropriate for very ill or el-
activity to food for optimum glucose control and derly patients, while more intensive control may be
prevention of hypoglycemia . All three meals should appropriate for healthy, stable inpatients.
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follow a consistent carbohydrate approach that em-
phasizes the importance of a mixed meal. Risk factors for hypoglycemia include aggressive gly-
cemic control, older age, recent hospitalization, ter-
6.Applying Systems minal illness, number of comorbidities, renal failure,
The recent ADA technical review discussed the use shock, mechanical ventilation, malignancy, hypoal-
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of protocols or standardized order sets for sched- buminemia and antecedent episodes of hypoglyce-
uled and correction-dose insulin, which reduces re- mia.
liance on sliding scale management for maintaining
glucose control in the hospital.A team or multidis-
ciplinary approach is needed to establish hospital
pathways and implement intravenous infusion of
insulin for the majority of patients having prolonged
NPO status outside of critical care units.

GCDC 2017