Hypoglycemia

Introduction
Hypoglycemia is a condition characterized by abnormally low blood glucose (blood sugar) levels, usually less than 70 mg/dl. However, it is important to talk to your health care provider about your individual blood glucose targets, and what level is too low for you.

Emergency complications

If blood sugar rises high enough or for a prolonged period of time, it can lead to two serious conditions.

·         Diabetic ketoacidosis. Diabetic ketoacidosis develops when patient don’t have enough insulin in body. When this happens, sugar (glucose) can't enter the cells for energy. Because of that blood sugar level rises, and body begins to break down fat for energy.

This process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually "spill over" into the urine. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and be life-threatening.

·         Hyperglycemic hyperosmolar syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high — greater than 600 mg/dL (33 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy.

Glucose is then spilled into the urine, causing increased urination. Left untreated, diabetic hyperglycemic hyperosmolar syndrome can lead to life-threatening dehydration and a coma. Prompt medical care is essential.

Presentation

Signs and Symptoms of Hypoglycemia (happen quickly)

·         Shakiness

·         Nervousness or anxiety

·         Sweating, chills and clamminess

·         Irritability or impatience

·         Confusion, including delirium

·         Rapid/fast heartbeat

·         Lightheadedness or dizziness

·         Hunger and nausea

·         Sleepiness

·         Blurred/impaired vision

·         Tingling or numbness in the lips or tongue

·         Headaches

·         Weakness or fatigue

·         Anger, stubbornness, or sadness

·         Lack of coordination

·         Nightmares or crying out during sleep

·         Seizures

·         Unconsciousness  (Mayoclinicorg, 2015)

Causes

·         Medications. One example is quinine (Qualaquin), which is used to treat malaria.

·         Excessive alcohol consumption

·         Some critical illnesses. Severe illnesses of the liver, such as severe hepatitis

·         Insulin overproduction

·         Fasting

·         Infection

·         Diet changes

·         Extrapancreatic causes

·         Insulinomas

·         Idiopathic causes 

·         Hormone deficiencies

·         Metabolic changes or activity changes

Investigations

Whipple’s triad gives indications of symptoms and signs of hypoglycaemia, a low plasma      glucose

concentration and resolution of symptoms and signs after plasma glucose returns to normal. 

HbA1c gives the assessment of glucose control.  

Liver function tests and thyroid function tests include any metabolic abnormalities regarding the low

level of glucose.  

Insulin radioimmunoassay is done to recognize islet cell tumor where it shows elevated insulin

levels.  

Blood and urine assays for sulfonylureas will detect factitious hypoglycaemia caused by these drugs

(Willacy 2013).

Management 

Treatment

1. Consume 15-20 grams of glucose or simple carbohydrates
2. Recheck your blood glucose after 15 minutes
3. If hypoglycemia continues, repeat.
4. Once blood glucose returns to normal, eat a small snack if your next planned meal or snack is more than an hour or two away.

15 grams of simple carbohydrates commonly used:

·         glucose tablets (follow package instructions)

·         gel tube (follow package instructions)

·         2 tablespoons of raisins

·         4 ounces (1/2 cup) of juice or regular soda (not diet)

·         1 tablespoon sugar, honey, or corn syrup

·         8 ounces of nonfat or 1% milk

·         hard candies, jellybeans, or gumdrops (see package to determine how many to consume) (Uptodatecom, 2015)

Glucagon

If left untreated, hypoglycemia may lead to a seizure or unconsciousness (passing out, a coma). In this case, someone else must take over.

Glucagon is a hormone that stimulates your liver to release stored glucose into your bloodstream when your blood glucose levels are too low. Injectable glucagon kits are used as a medication to treat someone with diabetes that has become unconscious from a severe insulin reaction. Glucagon kits are available by prescription. Speak with your health care provider about whether you should buy one, and how and when to use it.

The people you are in frequent contact with (for example, family members, significant others, and coworkers) should also be instructed on how to administer glucagon to treat severe hypoglycemic events. Have them call 911 if they feel they can't handle the situation (for example, if the hypoglycemic person passes out, does not regain consciousness, or has a seizure, if the care taker does not know how to inject glucagon, or if glucagon is not available).

If glucagon is needed:

1. Inject glucagon into the individual's buttock, arm or thigh, following the manufacturer's instructions.
2. When the individual regains consciousness (usually in 5-15 minutes), they may experience nausea and vomiting.
3. If you have needed glucagon, let your health care provider know, so they can discuss ways to prevent severe hypoglycemia in the future.  (Diabetesorg, 2015)

Medications uses are glucose supplements such IV dextrose, glucose elevating agents such as glucagon, inhibitors of insulin secretion such as diazoxide and Antineoplastic drugs such as streptozocin (Hamdy, Khardori & Vellore 2014). 

References

Uptodatecom. 2015. Uptodatecom. [Online]. [15 April 2015]. Available from: http://www.uptodate.com/contents/hypoglycemia-low-blood-sugar-in-diabetes-mellitus-beyond-the-basics

Hamdy, O, Khardori, R & Kenneth, J 2014, 'Hypoglyaemia', retrieved 16th of March 2015, http://emedicine.medscape.com/article/122122-overview

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [22 April 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/hypoglycemia/basics/symptoms/con-20021103

Diabetesorg. 2015. American Diabetes Association. [Online]. [29 April 2015]. Available from: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html