Hypoglycemia is the medical term for a pathologic state produced by a lower than normal level of glucose (sugar) in the blood. The term hypoglycemia literally means “under-sweet blood” (Gr. hypo-, glykys, haima). Hypoglycemia can produce a variety of symptoms and effects, but the principal problems arise from an inadequate supply of glucose as fuel to the brain, resulting in impairment of function (neuroglycopenia). Derangements of function can range from vaguely “feeling bad” to coma and (rarely) permanent brain damage or death. Hypoglycemia can arise from many causes and can occur at any age.
Causes of Hypoglycemia
The most common forms of moderate and severe hypoglycemia occur as a complication of treatment of diabetes mellitus with insulin or certain oral medications. Hypoglycemia is usually treated by the ingestion or administration of dextrose or foods digestible to glucose. Endocrinologists (specialists in hormones, including those who regulate glucose metabolism) typically consider the following criteria (referred to as Whipple’s triad) as indicative of hypoglycemia:
- Symptoms known to be caused by hypoglycemia.
- Low glucose at the time the symptoms occur.
- Reversal or improvement of symptoms or problems when the glucose is restored to normal.
However, not everyone has accepted these suggested diagnostic criteria, and even the level of glucose low enough to define hypoglycemia has been a source of controversy in several contexts. For many purposes, plasma glucose levels below 70 mg/dl or 3.9 mmol/L are considered hypoglycemic.
Treatment of Hypoglycemia
Management of hypoglycemia involves immediately raising the blood sugar to normal, determining the cause and taking measures to hopefully prevent future episodes.
- Avoid foods with elemental sugar: The first basic treatment is to avoid all foods that contain elemental sugar. This includes almost all desserts and junk foods as well as all non-diet soft drinks. A lot of people find that caffeine also stimulates the release of blood glucose and precipitates a reaction. That’s the reason why caffeine helps keep people awake and “gives” them energy—it’s really the increase in blood glucose giving them the extra energy.Beware of anything that comes in a box from the supermarket. The food industry loves to add sugar to things to entice you to eat their products. The worst offender you can think of are breakfast cereals. They not only put sugar in their product, but on their product. If you really wish to eat cereal, then eat Shredded Wheat, which has no added sugar.
- Eat smaller portions of food: The second basic treatment is to give your body small doses of food at more frequent times during the day (the frequency people use varies from 6 times a day up to 11 or 12 times a day). These snacks should, of course, be smaller portions of things that are digested slowly. Things that are digested slowly include protein and complex carbohydrates. Complex carbohydrates include whole grains and fresh vegetables. For comparison, simple carbohydrates include things like sugar.In addition, beware of everything that has ingredients that end in -ose, which denotes a sugar. These include dextrose, glucose, maltose, sucrose and sorbital. Fruits are sort of in a gray area with their fructose. If you have a fruit drink, then the sugars can be absorbed quickly. If you have applesauce, then the body has to do some breaking down of the applesauce before it can get to the sugar. If you have a whole apple, then the body has a lot of breaking down to do. You have to read labels to see if the products have sugar in them.
- Take carbohydrate: The blood glucose can be raised to normal within minutes by taking (or receiving) 10-20 grams of carbohydrate. This amount of carbohydrate is contained in about 3-4 ounces (100-120 ml) of orange, apple or grape juice (although fruit juices contain a higher proportion of fructose, which is more slowly metabolized than pure dextrose). Alternatively, about 4-5 ounces (120-150 ml) of regular non-diet soda may also work, as will about one slice of bread, about 4 crackers or about 1 serving of most starchy foods.
Starch is quickly digested to glucose (unless the person is taking acarbose), but adding fat or protein retards digestion. Symptoms should begin to improve within 5 minutes, though full recovery may take 10-20 minutes. Overfeeding does not speed recovery and if the person has diabetes, this will simply produce hyperglycemia afterwards.
- Use an IV for severe cases: If a person is suffering such severe effects of hypoglycemia that they cannot (due to combativeness) or should not (due to seizures or unconsciousness) be given anything by mouth, medical personal such as EMTs and Paramedics or in-hospital personnel can establish an IV and give intravenous dextrose, concentrations varying depending on age; i.e., infants are given 2cc/kg dextrose 10%; children, dextrose 25%; and adults, dextrose 50%.Care must be taken in giving these solutions because they can be very necrotic if the IV is infiltrated. If an IV cannot be established, the patient can be given 1 to 2 milligrams of Glucagon in an intramuscular injection.
- Take acarbose: One situation where starch may be less effective than glucose or sucrose is when a person is taking acarbose. Since acarbose and other alpha-glucosidase inhibitors prevents starch and other sugars from being broken down into monosaccharides that can be absorbed by the body, patients taking these medications should consume monosaccharide-containing foods such as glucose tablets, honey or juice to reverse hypoglycemia.
- Lower the dose of insulin or other medications: The most effective means of preventing further episodes of hypoglycemia depends on the cause. The risk of further episodes of diabetic hypoglycemia can often (but not always) be reduced by lowering the dose of insulin or other medications or by more meticulous attention to blood sugar balance during unusual hours, higher levels of exercise or alcohol intake.
- Avoiding extra carbohydrates: Many of the inborn errors of metabolism require avoidance or shortening of fasting intervals, or extra carbohydrates. For the more severe disorders, such as type-1 glycogen storage disease, this may be supplied in the form of cornstarch every few hours or by continuous gastric infusion.
- Hypoglycemia Drugs: Several treatments are used for hyperinsulinemic hypoglycemia, depending on the exact form and severity. Some forms of congenital hyperinsulinism respond to diazoxide or octreotide. Surgical removal of the overactive part of the pancreas is curative with minimal risk when hyperinsulinism is focal or due to a benign, insulin-producing tumor of the pancreas. When congenital hyperinsulinism is diffused and refractory to medications, near-total pancreatectomy maybe reserved as a last resort, but in this condition is less consistently effective and fraught with more complications.
- Hormone replacement therapy: Hypoglycemia due to hormone deficiencies such as hypopituitarism or adrenal insufficiency usually ceases when the appropriate hormone is replaced. Hypoglycemia due to dumping syndrome and other post-surgical conditions is best dealt with by altering diet. Including fat and protein with carbohydrates may slow digestion and reduce early insulin secretion. Some forms of this respond to treatment with a glucosidase inhibitor, which slows starch digestion.
- Fat and protein carbohydrates: Reactive hypoglycemia with demonstrably low blood glucose levels is most often a predictable nuisance that can be avoided by consuming fat and protein with carbohydrates, adding morning or afternoon snacks and reducing alcohol intake.
- Changing dietary patterns: Idiopathic postprandial syndrome without demonstrably low glucose levels at the time of symptoms can be more of a management challenge. Many people find improvement by changing eating patterns (smaller meals, avoiding excessive sugar, mixed meals rather than carbohydrates by themselves), reducing intake of stimulants such as caffeine or by making lifestyle changes to reduce stress.
In case of emergency due to low blood sugar, do the following:
- Safety is always first: Always follow the basics of first aid. There are many causes of unconsciousness that’re not related to diabetes or hypoglycemia. If you feel the area is not safe, stay back and summon help. You’re no help to the victim if you get hurt. Follow universal precautions and wear personal protective equipment if you have it.
- Give victim something sweet: If the victim is conscious and able to follow your commands, have the victim eat or drink something sweet. There are glucose gel products on the market just for this use. Other than gel products, juices work best. Victims can even eat frozen juice concentrate right out of the can with a spoon.
- Recovery position: If the victim is unconscious, place the victim in the recovery position and call 911.
- Stay with the victim: Monitor the victim and wait for the ambulance. Follow the basic steps for first aid while you wait.
It had been appreciated for over a century that severe illness is associated with hyperglycemia. However, for most of that time “stress-hyperglycemia” has been either largely ignored, or assumed adaptive. It’s now well established that both the degree and duration of hyperglycemia are independent risk factors for adverse outcome: whether for patients following severe brain-injury, severe pediatric-burns, critical-illness polyneuropathy, trauma, myocardial infarction, stroke, as well as for a heterogeneous group of ICU patients whether previously diagnosed diabetic or not.
As such, for severely hypoglycemic patients staying in the ICU longer than three days, maintaining blood glucose concentrations between 4.4–6.1 mmol·L–1 during ICU admission is associated with reduced in-hospital mortality, but more frequent hypoglycemic events. Intensive insulin therapy significantly reduced morbidity, but not mortality amongst all medical ICU patients.