Severe Hypoglycaemia Medication Protocol

Severe hypoglycaemia is a blood glucose under 3.0 mmol/L (and clinically any level) with confusion, seizure or coma, needing help from another person. It is a medical emergency, and the target after treatment is a glucose of 4.0 mmol/L or more.

Causes. Insulin and sulphonylureas, missed meals, alcohol, liver failure, sepsis, adrenal insufficiency, severe malaria and its treatment with quinine, starvation, and insulinoma.

Duration of risk. Sulphonylureas and long-acting insulin cause prolonged and recurrent episodes, so observation continues for 24 hours or longer.

Conscious and able to swallow. Oral fast-acting carbohydrate.

Unconscious, fitting, or unable to swallow. Intravenous glucose. Glucagon intramuscularly or subcutaneously when there is no intravenous access, which works only when glycogen stores exist, so it is weak in starvation, alcohol use and liver failure.

Sulphonylurea-induced. Octreotide as a second-line drug after glucose.

Special groups.

• Children: 10 percent dextrose by weight, and glucagon by weight.

• Pregnancy: use the usual adult treatment.

• Alcohol use or malnutrition: give thiamine 100 to 250 mg intravenously, without delaying glucose.

• East Africa: severe malaria, quinine and sepsis commonly cause hypoglycaemia, particularly in children, so check glucose in every febrile or unwell child.

• Oral: glucose 15 to 20 g (glucose tablets, or 150 to 200 mL of juice), repeated after 10 to 15 minutes if glucose is under 4.0 mmol/L.

• Intravenous: 10 percent dextrose 150 to 200 mL over 15 minutes, or 20 percent dextrose 75 to 100 mL over 15 minutes. 50 percent dextrose 50 mL (25 g) can be used through a large vein, because it is irritant.

• Glucagon: 1 mg intramuscularly or subcutaneously in adults and in children of 25 kg or more, and 0.5 mg in children under 25 kg.

• Children: 10 percent dextrose 2 to 5 mL/kg intravenously, repeated if the glucose stays low.

• Maintenance: 10 percent dextrose infusion at 100 to 125 mL/h, adjusted to glucose, until the patient is eating and glucose is stable.

• Octreotide: 50 micrograms subcutaneously every 6 hours (up to 100 micrograms) for sulphonylurea-induced episodes.

Monitoring. Check glucose at 10 to 15 minutes, then hourly for at least 4 to 6 hours, and every 1 to 2 hours for 24 hours with a sulphonylurea or long-acting insulin.

Stop rules. Stop the infusion when glucose stays at 4.0 mmol/L or more without it. Withhold or reduce the causative insulin or sulphonylurea.

Referral and escalation. Escalate for no response after two intravenous doses, persisting coma (look for other causes, including seizure or stroke), recurrent episodes, or suspected insulinoma, adrenal failure or liver failure.

Common errors. Relying on glucagon in malnourished patients, stopping glucose too soon after a sulphonylurea, missing alcohol and liver causes, and giving 50 percent dextrose into a small vein.