This is most common complication
associated with diabetes management, and the development of hypoglycemia
is an ever present possibility in all patients treated with insulin or
Hypoglycemic should be avoided, or at least recognised in the very early
stages, so that prompt corrective action can avert any serious consequences.
HIGH RISK PATIENTS
1) Patients at greater
risk from hypoglycemic sequelae:
2) Those who have difficulty
in perceiving hypoglycemic symptoms;
3) Those who do not spontaneously
recover from hypoglycemia;
4) The elderly, as well
as, infants and young children;
5) Patients with angina
pectoris, TIA's, renal and hepatic dysfunction, etc.;
6) Patients with erratic
eating habits and timings;
7) Patients whose work
may call for sporadic, sudden and vigorous activity.
|CLASSICAL SIGNS & SYMPTOMS
|| Neuroglycopenic (b)
|a) caused by increased activity of the sympathoadrenergic
system; may be triggered by a very rapid fall in blood glucose levels
b) caused by action on the central nervous system; requires a level
of blood glucose well in the hypoglycemic range
Patients need NOT show
all these classical signs and symptoms of hypoglycemia. This is especially
true of the elderly and the children.Thus, diagnosis may have to based
on clinical suspicion; if available, capillary blood glucose measurement
using finger prick test should aid diagnosis; in its absence, clinical
improvement with glucose administration aids diagnosis.
For a short list of some common hypoglycemic signs and symptoms seen
in the elderly and the in children see Appendix 8a
It is very important to rule out hypoglycemic reaction
occurring during sleep. These may not be severe enough to cause convulsions
or coma. The patient may complain that the experiences night sweats, has
recurring vivid dreams or nightmares, has early morning headaches which
disappear after he takes his breakfast.
Such complaints must be investigated to rule out nocturnal hypoglycemia.
IF IN DOUBT, TREAT AS HYPOGLYCEMIA UNTIL PROVEN OTHERWISE
Some patients may manifest sympathoadrenal signs
and symptoms, even if the blood glucose is not actually in the "hypoglycemic"
range. It is often seen with a very rapid drop in the blood glucose level.
|ABSENCE OF SYMPATHOADRENAL
SIGNS AND SYMPTOMS
Patients may manifest neuroglycopenic signs and symptoms
in the absence of sympathoadrenal reactions under certain conditions:
|ABSENCE OF SYMPATHOADRENAL SIGNS AND SYMPTOMS
1) If the blood glucose level fall very slowly;
2) Diabetics with significant neuropathic involvement;
3) Certain drugs such as beta blockers may mask the sympathoadrenal
4) Some elderly diabetics.
|NON-CLASSICAL SIGNS AND SYMPTOMS
Many diabetics exhibit signs and symptoms which are
truly hypoglycemia reactions although they may not fall into the "classical"
Patients who become excessively quiet, or conversely, very boisterous,
show a lack of interest in normal activities, throw uncalled for temper
tantrums, become morose, ambitionless, complain of feeling faint, complain
of perioral paraesthesias, etc. may all be manifesting hypoglycemia.
In simple terms,
|ANY DIABETIC UNDERGOING
TREATMENT WHO SHOWS A BEHAVIOUR PATTERN WHICH IS NOT IN KEEPING WITH
HIS NORMAL BEHAVIOUR, SHOULD HAVE THE PRESENCE OF HYPOGLYCEMIA RULED
PRECIPITATING FACTORS FOR HYPOGLYCEMIA
It would be worthwhile
to understand the most common precipitating factors for hypoglycemia are
and thus, try and avoid these episodes.
FACTORS FOR HYPOGLYCEMIA
1) delayed or missed meals;
2) unexpected calorie intake reduction;
3) sudden, undue, vigorous activity;
4) errors in dosage and/or timing;
5) renal and hepatic dysfunction;
6) defective counter-regulation;
7) interaction with other drugs;
8) subtle hypothyroidism and/or adrenal insufficiency
The management of hypoglycemia
in a patient is fairly simple when the diagnosis is done at an early stage.
All that one may have to do is to have a meal, snack or even a beverage
with some easily absorbed carbohydrates. In an emergency, one could also
take some simple sugars or a drink with simple sugars.
It is very important that after patients have taken simple sugars and
become better, they must take a meal having complex carbohydrates. This
will be slowly absorbed and help in keeping the blood glucose levels even
after the rapid effect of the simple sugars has worn off, especially when
the hypoglycemia causing agent is still present in the body.
If the patient is unconscious of cannot take anything orally, inject 50
- 100 c.c. of 25% glucose i.v. Once consciousness is regained, treat as
If i.v. is not feasible, 0.5 to 1 mg of glucagon i.m./s.c. can be given.
Initially inject 0.5mg and if there is no change in the condition, the
other 0.5mg can be injected. Rationale for this is that in some patients
glucagons can cause nausea and vomiting and would prevent oral intake
by the patient even if consciousness returns.
Glucagon is effective in treating hypoglycemia only if sufficient liver
glycogen present, therefore glucagon has virtually no effects on patients
in states of starvation, adrenal insufficiency, or chronic hypoglycemia.
Once consciousness is regained, treat as above.
For a more detailed discussion on the use of Glucagon in the management
of hypoglycemia, see Appendix 8b