Hypoglycemia: Diagnosis and Management (Nursing)

00:00 So, how is hypoglycemia diagnosed? Neonates who are suspected to be at high risk for hypoglycemia, you're just going to check their blood sugar. So if they have any of the symptoms of hypoglycemia, if they're jittery, tremoring, especially if a neonate presents with a seizure and they have never had a seizure before, the first thing that you do is check glucose because that is an easily reversible condition. If they have hypoglycemia, we can give some glucose and we can fix that issue. Additionally, if the infant has been large for gestational age, if they have had perinatal stress. So if they have an infection, we're going to want to check that glucose. If they're premature, we're also going to be checking that glucose because they're at high risk for hypoglycemia. Infants of diabetic mothers, anybody who has family history of hypoglycemia. If there's a congenital syndrome, you're going to want to check the blood sugar because they're at higher risk. If there's abnormal facies and by facies I mean if there are any abnormal facial features, if there's just something that doesn't look quite right about that infant, that might indicate a congenital syndrome that just hasn't been diagnosed yet. So you're going to want to check blood sugar in those infants as well. So, for any infant or younger child, if you got a blood sugar that's less than 60 mg/dL, that is hypoglycemia. So what do we do if we have hypoglycemia? How do we manage them? Goal is to achieve rapid normalization of blood glucose levels.

01:41 Often, hypoglycemia is somewhat of an emergency especially if your patient is having seizure or any neurological changes. So what are we going to use? If your patient's not having a lot of symptoms, we might have time to use oral carbohydrates. If you're in a more emergent situation or if you're in the hospital and you're able to give IV, you're going to give IV glucose. So, if the child is conscious, they're not having that many symptoms but you know that blood sugar is starting to drift down and it's a little bit low, then you can give rapid acting carbohydrates and these can be given by mouth. So it's going to be 15 grams per children. And what would be a rapid acting carbohydrate? So, 120 mL or 4 ounces of juice; orange juice, apple juice, those are great options, they're very sugary.

02:34 You could give a tube of glucose gel if you're in the hospital and you have that available to you or 4 glucose tablets. That's going to equal about 15 grams per children. Now the dose for infants is a little bit smaller, it's 0.2 g/kg for infants.

02:53 Often you're not going to be able to really dose that out if you're just giving some juice or even a tube of glucose gel. So, just know that you're going to give less for infants. So if you are going to give 4 ounces to a child, you might only give 1 or 2 ounces to an infant and then recheck that blood sugar. It's more important to get that blood sugar elevated and out of the hypoglycemic range than it is to have an exact dose of oral carbohydrate. So what happens if your patient is experiencing worse symptoms or if they have altered consciousness? What we're going to want to do is obtain IV access and administer IV dextrose. We're going to give an initial bolus and that's going to be 2 ml/kg of 10% dextrose and we're going to give that IV. So, after you do this, you are going to want to check and see if it worked. Right? So any time you do an intervention, then you want to turn around and you want to do some type of assessment to see if that intervention helped. So if the glucose is increased after 15 minutes, then you're all clear. If it hasn't increased, you're going to repeat that dose until you get a glucose level that is in a normal range. After that, you may end up needing to start a dextrose infusion. So you can start the infusion after those initial boluses and after the blood sugar has gotten to a more normal range. Infants are going to need a GIR which is a glucose infusion rate of 5-6 mg/kg/min and typically it's going to take 10% dextrose. So that means D10 normal saline to give you that GIR. Older children are going to need a GIR, remember that's glucose infusion rate, of around 2-3 mg/kg/min. So, older children need a little bit less glucose. And typically 5% dextrose is going to do that which is why you often see IV fluids in the form of D5 normal saline. What happens if you can't get IV access and you've got hypoglycemia? Well, don't worry, we do have an alternative, you can give glucagon.

05:09 So glucagon dose is going to be 0.5 mg for any one less than 25 kilos or it's going to be 1 mg for anyone greater than 25 kilos and you can give this IM.

05:23 Glucagon is only effective for insulin-mediated hypoglycemia and so this can make glucagon a way to diagnose if the cause of hypoglycemia is not insulin mediated. But if it is insulin mediated, the glucagon will work well. So, earlier I talked about glucose infusion rate and you don't need to memorize this formula. Generally, it's going to be the provider that determines what the glucose infusion rate is, but just for your reference so that you understand what it is, I've given you the formula here. So the GIR is equal to the percentage of the dextrose times the rate of the infusion, which is your ml per hour, and that's going to be divided by 6 times the patient's weight in kilo. And so remember that infants need a GIR that's a little bit higher, 5-6 mg/kg/min, and typically that translates to about 10% dextrose, so D10 normal saline for example. An older children need a GIR of 2-3 mg/kg/min and typically that will translate to 5% dextrose in IV fluid, so a D5 normal saline. If you have a patient that's on total parenteral nutrition though and you're not running a D5 or a D10, then they calculate the GIR to make sure they put enough glucose in the fluids. So that's a reason for using GIR. So, we need to be able to monitor and see if our blood glucose levels are where they need to be. We are going to monitor until at the very least our blood glucose levels are above 70, which is a more normal range, and if you've had to treat for hypoglycemia, we're going to do this every 15 minutes until we get several blood glucose checks that are within a normal range. Once we get blood glucose levels that are more stable, we might check them every hour for several hours and then once we have determined that our GIR is enough or we have corrected any underlying problem that cause the hypoglycemia and we think our blood glucose is going to be stable, we can further space those out. So, at that point maybe you're only checking them every 4 hours.

07:43 Once we have determined that that is stable, then you can space those out to daily.

07:48 So once the cause of the hypoglycemia is determined, then a long-term plan is going to be decided on by the provider. Sometimes it's just a transient illness that causes the hypoglycemia and there might not be any issues, but if it's a particular disease then we will have to make sure that this hypoglycemia doesn't happen again. Patients are often going to be followed by the endocrine service and they will be responsible for long-term followup.