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.