1. Hypoglycaemia Diabetes Outreach (June 2011)

2. 2 Hypoglycaemia Learning outcomes >Can state what hypoglycaemia is >Be able to assess who is at risk of hypoglycaemia >Be able to recognise a hypo event >Can state the treatment of a hypo in a health service and in the community >Is aware of the ways that hypo’s can be prevented.

3. 3 >In people with diabetes who are at risk, hypoglycaemia can cause signs and symptoms. >Hypoglycaemia is usually defined as a BGL less than 4mmol/L. >The BGL at which signs and symptoms occur can vary from person to person. What is hypoglycaemia?

4. 4 Features of hypoglycaemia Symptoms of hypoglycaemia occur as a response to adrenaline (pale skin, sweating, shakiness, palpitations, tingling especially around the lips, feeling of anxiety). Due to decreased glucose in the brain (hunger, confusion, behaviour changes & psychological reactions, seizures and coma).

5. 5 Signs and symptoms Signs blood glucose level < 4.0mmol/L Symptomatic (sometimes) unconscious Symptoms: hunger / sweating faintness / dizziness trembling palpitations headache irritability / confusion unconsciousness

6. 6 Causes of hypoglycaemia >missing or delaying a meal or snack >inadequate carbohydrate intake >over-administration of insulin/OHA >prolonged exercise >excessive alcohol >vomiting.

7. 7 Who’s at risk? Consider >types of diabetes >age of the person >duration of diabetes >type of medication >hypo awareness >diabetes complications >weight >exercise >excessive alcohol intake.

8. 8 Treatment of conscious person Step 1 BGL <4.0mmol/L give 15g fast acting carbohydrate (CHO) eg 90ml Lucozade, or 15g glucose tablets or equivalent. Step 2 Test BGL at 10 mins. If over 4 proceed to step 3, if under repeat step 1.

9. 9 Treatment of conscious person Step 3 Give slow acting CHO eg 2 biscuits or 1 piece of fruit or 1 cup (250ml) of milk or equivalent or the person’s regular meal if available. Step 4 Ensure person receives and eats a normal meal (adequate CHO serves) when next due.

10. 10 Unconscious hypoglycaemia >If the person is unable to safely swallow then glucagon needs to be administered either IM or SC. >People at significant risk of unconscious hypo need to receive education about glucagon. A caregiver or family member will require training. >In a hospital or health service, nurses can administer glucagon using a standing order. >If no response to glucagon 50% IV glucose will need to be ordered by MO.

11. 11 Administration of: Glucagon (IM) is used when a person is unconscious. Given intramuscular (but can be given subcutaneous or intravenously). Requires approx 6-10 minutes for peak onset of action. Glucose (IV) given as 10ml of 50% glucose intravenously.

12. 12 Diabetes Manual 2010

13. 13 Follow up Follow-up post severe ‘hypo’: >reassess person 15-30mins post hypo >check BGL after 30mins from initial time if level is <4mmol/L repeat step 1 & 2 >may need IVT (5% Dextrose) >BGL 2-4 hourly for 12-24 hours (depending on severity and duration) >documentation of event.

14. 14 ‘Hypo’ kit for health services A ‘hypo’ emergency kit can be assembled and placed in every ward or community health area and should contain at least the following: Quickly digested CHO: 1 bottle 50g Lucozade (90ml = 15g CHO) Slowly digested CHO: Biscuits.

15. 15 ‘Hypo’ kit for health services

16. 16 Hypo action plans in the community >All people at risk of hypo should have an action plan. >A hypo kit is central to this action plan. >Ask the person what foods they would like to keep in their hypo kit. >A hypo kit makes sure the person has planned for a hypo in various situations.

17. 17 Case scenario Lucy is 70yrs old. She has had type 2 diabetes for 20yrs. She is on a reduced dose of Metformin, Daonil (sulphonylurea) and a basal insulin. Over the past 4 years her weight has dropped slightly from 63kgs to 57. She lives alone.

18. 18 My ‘hypo’ plan BG___________________________ Step 1at home___________________________ out / car___________________________ Step 2monitor BG – 10-15 min and repeat step 1 until BG over 4 or____________________________ Step 3at home____________________________ out / car____________________________ Step 4monitor BG – 1-2 hour increasing gap time until happy no repeat hypo or____________________________ NB___________________________________________________

19. 19 Question >Is Lucy at risk of hypoglycaemia? >What makes her high risk? >How would you address the risk factors? >Use the hypo action plan on the next slide to assist with the discussion.

20. 20 Summary >Important that nurses assess the persons knowledge and self care of hypoglycaemia. >People should have an action plan in place for hypoglycaemia. >All health services and hospitals should have a protocol in place for treatment of hypo and a hypo kit that is easily accessible in all patient care areas.

21. 21 References >Cryer P E, Davis S N, and Shamoon H S (2003) Hypoglycemia in diabetes. Diabetes Care, 26(6): p1902-1912. >Diabetes Outreach (2009) Diabetes Manual, Section 4: Hospitalisation, Section 11: Unstable diabetes. >Diabetes Outreach (2011) Low blood glucose in type 2 diabetes (hypoglycaemia) factsheet. http://diabetesoutreach.org.au/consumer/defa ult.asp

22. 22