Alterations in Pancreatic Function: Hypoglycemia (Nursing)

00:00 Now, we're going to discuss another endocrine disorder and we're going to talk about hypoglycemia. So, we'll talk a little bit about the definition and some physiology, how this is going to present in your patients, a little bit about diagnosis, and then some management. So, when we think about hypoglycemia, this is a deficiency of glucose in the bloodstream. So you do not have enough glucose in the bloodstream. Here, we see a glucose level that is okay. When we have hypoglycemia, that gauge really kind of goes to empty and we just don't have enough glucose there to generate the energy that we need. The plasma glucose level at that point is going to be low enough to cause some signs and symptoms in your patient. So, glucose homeostasis in infants and children is really important.

00:55 And why is that the case? Well, it turns out that glucose is the preferred fuel of the brain. So if you brain is going to be working properly, it needs glucose to keep it running. So, to ensure an adequate fuel supply, the body must adapt to those times when we're not actually taking glucose in. So if you're not eating, then the body has to figure out how to keep some glucose getting to that brain even though you're not actively taking it in. So, the brain can only store, you know, trivial amounts of glucose at any given time and it stores it in the form of glycogen. There are multiple systems in place that ensure that your body is going to keep running and that your brain still gets the fuel it needs while you're actively not taking in glucose. And abnormalities in these kind of fasting regulatory system, so the systems that our body puts in place to ensure energy gets to the brain while we're not active eating. Abnormalities in those regulatory systems really are going to cause problems and that's where the hypoglycemia comes in. So what happens while we're fasting? If we're not taking in glucose, how does our body keep those energy levels up? So if you're not eating, your insulin levels are going to go down, but it turns out that you got other hormones that will step in. You've got some glucagon, cortisol, some epinephrine, and those changes will activate 3 metabolic fasting systems. So, you don't need to memorize these but just know that there's glycogenolyse, lipolysis, ketogenesis, and gluconeogenesis. So, that's a mouthful but all of these will help your body continue to produce energy even when you're not actively eating. So, activation of these metabolic fasting systems will lead to an increase in your hepatic glucose production. So your liver will kind of dive in and help create some glucose while you're not eating. It's going to your body overall during these fasting systems. It's going to need less glucose. So there's a decrease in the amount of glucose that you actually need. And it's going to give the body an increased availability of some alternative fuels so you can think free fatty acids and ketones. So as glucose production declines and ketone levels increase, the brain eventually will switch to ketones as the main source of fuel but remember it really prefers the glucose. So how are infants and children different than adults? So, glucose levels decline more rapidly in infants and children and if you think about this it makes a lot of sense. Right? Babies eat how often? I mean, at the very beginning of their lives they're eating every 2 hours. This isn't because they're trying to be annoying although, you know, waking up every 2 hours can be difficult. It's because they don't have the mechanisms to keep the energy going. If they're not actively eating, their glucose levels decline more rapidly so they have to eat more often. Transition to ketogenesis occurs earlier in infants and children and their relatively larger brain volume versus their overall size means that they just have a higher glucose utilization rate for the amount of energy that they're taking in. So these changes mean that infants and children need to eat more often than adults do. So, transition to ketogenesis also occurs after 24 to 48 hours in older children and adults and 12 to 18 hours of fasting in infants. And remember the brain doesn't prefer ketones so we want to avoid getting to that.

04:50 There are several different categories of hypoglycemic disorders and we're not going to really get into the specific diseases.

04:57 There are many diseases that can cause hypoglycemia. So since we're not going to get into the specifics, I'm giving you just a few broad categories. Again, you don't need to memorize these but sometimes it can be helpful to know the different types of things that can cause hypoglycemia.

05:13 So, if you have insulin-mediated disorders, you know think diabetes. If you give too much insulin in diabetes, then you end up with hypoglycemia. Fatty acid oxidation disorders can cause hypoglycemia.

05:28 Ketotic hypoglycemic disorders. Disorders of gluconeogenesis so the body is just not really able to produce the glucose it needs. And then there are many other causes including toxic ingestions and sepsis, and again you don't need to memorize all of those causes.

05:46 So lets talk about how hypoglycemia will present in infants and children. The clinical presentation can be broken up into neurogenic symptoms, neuroglycopenic symptoms, and some nonspecific symptoms. When you have a blood glucose of less than 55 to 60, you're going to get a lot of neurogenic symptoms and when that blood glucose drops really low, less than 50, you're going to have the neuroglycopenic symptoms.

06:16 And then nonspecific symptoms can happen at any point. So, what does that actually look like? Neurogenic symptoms typically occur before the neuroglycopenic symptoms. That is one thing that is good to note. So, what is this going to look like for your patient? For neurogenic symptoms, that is really mediated by the sympathetic nervous system. So, you're going to have sweating, you're going to have tremors, the patient's going to be jittery, they might have some palpitations, their hearts going to be beating really quickly, they might feel hunger, they might have paresthesias or pallor. Now, if we move over into the neuroglycopenic symptoms, that is really because of the insufficient brain glucose and because the brain is not getting enough energy. So, your patient is going to start getting lethargic, they're going to slow down a little bit, they might feel confuse, they might get a little irritable, maybe they have some uncharacteristic behavior, maybe they're normally fairly pleasant child and all of the sudden they're pretty cranky. They might experience weakness or they might have loss of consciousness, seizure, even coma if that blood glucose drops low enough. In addition to this because infants and small children often can't tell us exactly what they're experiencing, we have some nonspecific symptoms. So in infants in particular, you may only notice irritable or lethargy. They may stop eating because they're not feeling great so they're not going to feed well. You might notice some cyanosis or tremors. They might be a little bit jittery. You might see some hypothermia. They might have poor tone. Maybe all of the sudden the infant looks floppier than they normally do and that's hypotonia. You might notice that their respiratory rate increases, that tachypnea, and they might stop breathing altogether either periodically and then start breathing again or they might actually just stop breathing. The other critical thing to note is that infants might present with seizure as a very first indication of hypoglycemia.