Most people think of hypoglycemia as having the classic symptoms of shakiness, sweating and hunger. When keeping blood sugars in the normal range, these symptoms often disappear or only occur occasionally; they are replaced by numb lips, numb tongue, confusion (repeating the same task or inability to perform familiar tasks such as dialing a phone), blurry vision or double vision. Many times these symptoms go unnoticed until it's too late and someone else needs to treat the reaction. In retrospect, most people can remember something about how they felt before it became impossible to self-treat. It is important to try to remember what it was, so that treatment will be instituted immediately the next time it occurs. It will also inspire you to have something readily available at all times to immediately treat these reactions. (See: Glucagon: Insulin "Antidote" Not in All Pumpers' Homes)

One of our patients was a competitive runner. He was training for an upcoming race and fell when running down a hill. He realized he was probably low, but had only one tube of Insta-Glucose. He was still several miles from home and knew this was not enough to get him there. He passed a police station on the way and requested a ride home. He was told that they were not a taxi service and he was incapable of arguing though he did show his ID bracelet.

He did make it home on his own somehow, but was extremely frightened by the experience. He now carries enough Insta-Glucose to get him home from any distance!

Another patient had anticipated having a large dinner so increased her pre-dinner bolus. She didn't really eat more and then proceeded to go out with friends. When driving home at 2 a.m. she realized she was in trouble when she couldn't keep her car between the lines. She had nothing in her pockets, purse or car to treat her reaction. She knew she needed to get off of the highway but was unable to find the exit ramp. Another driver saw her weaving and motioned for her to follow him off the exit ramp, which she did. Luckily he was a good Samaritan and flagged a policeman who fortunately had a relative with diabetes. She was still able to communicate at this point and told him she needed sugar. He bought her two candy bars and she recovered but was terribly frightened. She now never goes anywhere without some form of glucose in her purse.

Brian was a college student who received a ski trip to Colorado for his 21st birthday. On his way out for a night at the bar he checked his glucose and discovered it was 2 mmol/L. He ate 3 glucose tabs and was on his way. He had a good time drinking with his buddies and came home around 2 a.m. and flopped into bed. At 5:30 a.m., his roommates were awakened by him having a seizure. They called 911, but in the meantime, one of his friends gave him an injection of insulin since he thought this would help! He was brought to the ER, given glucose, but was not discharged. He was admitted for 24 hours of observation due to his insulin injection of unknown amount.

He lost a day of his skiing time, but luckily no more than that. He is now careful to always check his glucose before going to sleep, especially if he's been out drinking. Also, his friends now know about glucagon.

Close to 3/4 of severe hypoglycemic episodes occur during sleep. It is particularly important to be aware of this.

You don't need to experience a reaction like any of those described if you simply know how to treat hypos.

1. In hospitalized patients, efforts must be made to ensure that patients using insulin have ready access to an appropriate form of glucose at all times, particularly when NPO (not eating by mouth) or during diagnostic procedures [Grade D, Consensus].¹

2. In adults, mild to moderate hypoglycemia should be treated by the oral ingestion of 15 g of carbohydrate, preferably as glucose or sucrose tablets or solution. These are preferable to orange juice and glucose gels [Grade B, Level 2 (4)]. Patients should be encouraged to wait 15 minutes, retest BG and retreat with another 15 g of carbohydrate if the BG level remains <4.0 mmol/L. In smaller children(<5 years of age or <20 kg), 10 g of carbohydrate may be used initially [Grade D, Consensus]. ¹

3. Severe hypoglycemia in a conscious adult should be treated by the oral ingestion of 20 g of carbohydrate, preferably as glucose tablets or equivalent. Patients should be encouraged to wait 15 minutes, retest BG and retreat with another 15 g of glucose if the BG level remains <4.0 mmol/L [Grade D, Consensus]. ¹

4. Severe hypoglycemia in an unconscious individual >5 years of age, in the home situation, should be treated with 1 mg of glucagon subcutaneously or intramuscularly. In children ≤5 years of age, a dose of 0.5 mg of glucagon should be given. Caregivers or support persons should call for emergency services and the episode should be discussed with the diabetes healthcare team as soon as possible [Grade D, Consensus]. ¹

5. In the home situation, support persons should be taught how to administer glucagon by injection [Grade D, Consensus]. ¹

6. For severe hypoglycemia with unconsciousness in adults, when intravenous (IV) access is available, glucose 10 to 25 g (20 to 50 cc of D50W, Dextrose 50% in water) should be given over 1 to 3 minutes. The pediatric dose of glucose for IV treatment is 0.5 to 1 g/kg [Grade D, Consensus]. ¹

7. In hospitalized patients, a PRN (when necessary) order for glucagon should be considered for any patient at risk for severe hypoglycemia (i.e. requiring insulin and hospitalized for concurrent illness) when IV access is not readily available [Grade D, Consensus]. ¹

8. To prevent repeated hypoglycemia, once the hypoglycemia has been reversed, the person should have the usual meal or snack that is due at that time of the day. If a meal is >1 hour away, a snack (including 15 g of carbohydrate and a protein source) is recommended in the absence of complicating factors [Grade D, Consensus]. ¹

REFERENCE:

1. Begg IS, Yale, Houlden RL, et al. Canadian Diabetes Association's Clinical Practice Guidelines Expert Committee: Hypoglycemia: 2003: S44

When you strive for tight control of glucose, there is less time to treat reactions, but the end results are well worth the effort: eyes, kidneys and nerves and protect your life expectancy!

JoAnn Ahern, RN, MSN, CDE

JoAnn is a DCCT Trial Coordinator from Yale University. She followed many pump patients in the DCCT and at Yale where the first U.S. research paper on pumps was published in the late 1970's. JoAnn's comments in this article are not specific to pump patients, but to anyone using insulin.