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HYPOGLYCEMIA
DEFINITION
Hypoglycemia or low blood glucose is a clinical state associated with < 50mg/dl or low plasma glucose with typical symptoms.
Whipples triad =
venous plasma glucose <50mg/dl. Classical symptoms. Relief of symptoms with glucose.
DCCT Definition
Event resulting in seizure,coma ,confusion or symptoms like sweating,palpitation,hunger with finger stick glucose < 50 mg/dl and amelioration of symptom by elevation of blood glucose. Prodromal symptoms occuring before the event are well remembered. Severe hypoglycemic symptoms requiring hospital admission and treatment with IV glucose or glucagon.
Over utilization
hyper insulinism insulinoma exogeneous insulin overdose. auto immunity Normal insulin level extra pancreatic tumour carnitine def, cachexia.
Factors that precipitate hypoglycaemia Excessive insulin or SU administration- Error by patient or doctor. - Poor matching to patients lifestyle.
Increased insulin bioavailability-Exercise. -Injecting into abdomen. -Change to human insulin/analogs -Insulin antibodies. -Mismatch of syringes
Common symptoms
Autonomic Adrenergic Sweating Palpitation Tremor Hunger Neuroglycopenic General
confusion nausea drowsiness headache speech problems incoordination atypical behaviour diplopia
Grading of Hypoglycaemia
Grade 1 or mild : patient can recognize hypo and able to self treat Grade 2 or moderate : severe hypo prevents patient from self treating but with assistance oral treatment is possible. Grade 3 or severe : severe degree of neuroglycopenia requiring parenteral glucagon/dextrose.
Hierarchy of Glucoregulation
Insulin (83 + 9 mg) Glucagon (68 + 2 mg) Epinephrine (68 + 2 mg) Growth hormone (66 + 2 mg) Cortisol (58 + 6 mg) Symptoms of hypoglycemia (53 + 2) Cognitive dysfunction (49 + 2)
Nocturnal Hypoglycemia
Is common (biochem hypos occur frequently). Asymptomatic/morning headache/hangover. Often identified by partner: sweating, fretting. May lead to sudden death. Unsatisfactory time action profile of certain insulins; physio defences against hypo reduced in flat position; sympathetic responses to hypo reduced in slow wave sleep Dawn phenomenon vs Somogyi effect.
Morbidity of Hypoglycemia
CNS Coma/convulsions/transient deficits/ataxia/brain damage/ intellectual impairment. Psycho Cognitive disorders/personality changes/ behavioural disorders/ automatism/ psychosis. CVS Arrhythmia/MI/TIA/stroke. Eye Vitreous haemorrhage Musculoskeletal Fracture/accidental injury.
Hypoglycaemic Unawareness
Absence of classical adrenergic warning symptom,
More vulnerable to develop severe hypoglycaemia Counter-regulatory failure :
Glucagon failure - 5 yr.to20 yr. Adrenaline failure - follows then 25 times higher risk for severe hypoglycaemia
Hypoglycemia unawareness
Perception of early warning symptoms impaired. Is not an all-or-none phenomenon. Affects one quarter of Type 1 diabetic patients. Correlates with glycemic control ? Duration of diabetes ? May be Acute or Chronic (Central autonomic failure).
increased full may be decreased shallow or normal normal,may be increased clammy,sweating moist normal normal no acetone brisk reflexes
increased weak may be decreased rapid and deep decreased dry dry reduced reduced acetone may be present diminished
Symptoms,signs and coma laboratory findings Laboratory tests urine glucose plasma glucose 200mg/dl plasma acetone plasma bicarbonate plasma CO2 blood pH
hypoglycemic coma
hyperglycemic
-ve to +ve depending on time of last voiding -ve to +ve -ve normal normal normal
+ve +ve greater than usually present low less than 20mg/litre diminished less than 7.35
MANAGEMENT ALGORITHM
Patient conscious Oral glucose/sucrose Patient unconscious IV glucose (50%) IM/SC glucagon
Recovery
Follow up
CAUTION
Glucagon may lose effect with repeated use. Glucagon is contraindicated in SU induced hypos. SU induced hypoglycemia may be very prolonged.It can be more fatal than insulin induced hypoglycemia. Duration of treatment depends on cause of hypo
Increase in SU effect
Salicylates, probenecid, sulfonamides, nicoumalone, fluconazole [inhibits CYP2C9 which metabolizes glimepiride], ketoconazole, ciprofloxacin [inhibits CYP3A4 which metabolizes glibenclamide], gatifloxacin
Neonatal hypoglycemia
Hypoglycemia in the immediate postpartum period needs recognition,as this phenomenon is transient. Every newborn of diabetic mothers must be given a 5% glucose infusion for the first six hours and subsequently blood glucose monitored to prevent potentially fatal hypoglycemic convulsions.
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