Does anyone in acute care utilize a protocol for hypoglycemia management in an inpatient setting that utilizes oral glucose, D50, glucagon or any other hyoglycemia modality?  About a year ago we put our protocol into place and not only did we learn some things but we have been able to act on hypoglycemic events without having to wait an hour for a doctor's order.  Anyone have any thoughts, ideas or comments they would like to share on this topic?  Thanks!

I don't know about hospital inpatient settings, but I do know about the effect of D50, oral glucose, and, in principle, glucagon.

All these raise glucose.  And you can't get in short term trouble with high glucose, unlike low glucose, which can be a big short term problem as you know.

The problem with high glucose comes with persistent high glucose over years.  You might give D50 or oral glucose inappropriately because glucose is OK, but it won't hurt the patient, while failure to do anything for an hour when glucose is low and falling can seriously hurt the patient.

If the amount of glucose you give is modest, say 10g to 20 g, you will only kick the patient's glucose up by 30 to 80 mg/dl, which isn't going to hurt if they aren't hypoglycemic, but will keep them out of danger, for a few hours anyway, if they are.

The only problem with giving glucose for possible hypoglycemia is giving too much.  This is common with Type 1 patients on their own.  They often overdo it, and wind up way too high an hour later.  They only need one or two of those commercial glucose tablets, usually, because that gets them out of the woods and able to test glucose without assistance, at which point they can take another tablet if glucose continues to trend down.

But not giving glucose to a patient that is below 50 mg/dl and heading lower can leave you with a patient below 30 mg/dl an hour later, which is not something you want to defend with the weak protest "I had to wait for doctor's orders".

Giving 10g glucose isn't at all comparable to giving a drug, even in a hospital, provided the patient isn't going into surgery.

I just found a hypoglycemia protocol for you on the AACE website
Go to http://resources.aace.com/PDF//Section_05-Final-Inpatient_Non-ICU/Hyperglycemia_Non-ICU_Protocols/Hypoglycemia_Treatment_Protocol.PDF

Hi Patricia,

 Thanks for finding this for me. It looks pretty much like what we were using.  Everyone must remember that these protocols MUST be ordered by a physician, NP or PA.  The patient must have all of those items ordered and the RN chooses from those items ordered.  We got into trouble with the regulatory bodies when we first set it up as an algorithm because they pointed out the RN cannot prescribe the course of treatment. It must already be ordered and then the RN can choose, depending on the patient's level of consiousness and ability to swallow, which modality should be utilized.

Thanks!

Judy, and all,

We just changed our hypoglycemia protocol when we instituted a new basal/bolus insulin order sheet in my hosptial.  Previously, only the nurses in the intensive care units could administer D50 IV push without a physician present.  So now, if the patient is less than 70 mg/dl but conscious, they get oral glucose.  If they are not swallowing well, or falling more but still conscious, they receive glucose gel which is kept ibn all of our med carts (Pixys).  If they are unconscious and do not have IV access, they get glucagon.  And if they are < 70 mg/dL, unconscious and with IV access, they get D50 IV push administered by the RN on the floor, without waiting for an MD order, or a MD to come to the patient's room.

The RNs on the floors were very happy to have this in place since they felt, in the past, they were waiting for the physician to get to the floor, after they had the D50 set up and ready to go.  This has helped to shorten the time anyone with diabetes is unconscious, and it has helped the RNs to feel more comfortable with their options for treating this unwanted occurence.

Donna

Great job, Donna!

Hi Donna, thanks so much for describing your process.  Just to clarify though, the D50, Glucagon and glucose gel are already ordered by the physician when the patient is identified as someone who could become hypoglycemic or does the RN, knowing the algorithm, choose which he/she needs and then gets the order later?  Thanks for clarifying for me.

These hypoglycemia protocols are part of our insulin order sheet, Judy.  So by the physician prescribing insulin, he/she is prescribing this hypoglycemia protocol as well.  It is up to the RN to make the assessment as to whether or not the patient is conscious, able to swallow, etc, but the protocols are automatically in place.

The only consequence of D50 IV push, is that if a person were unconscious secondary to a cerebral bleed, D50 could increase the bledding (it's an osmotic diuretic-glucose).  So it's imperative that a capillary glucose be performed PRIOR to any treatment.  If the patient were unconscious and the glucose was over 70 mg/dL, a rapid response would be called immediately and glucagon/ D50 would not be administered.

I hope this is clear.

Donna

Got it!  Thank you so much for elaborating on it for me, I appreciate it.  Our system is set up a little differently. We have the 3 items (D50, glucagon, oral glucose) set up as an orderset by themselves, not dependent on an insulin order.  I like your system better because you will always have the insulin order with the hypoglycemia set attached to it.  I am going to suggest a modification of our system. Thank you!

Some of the hypoglycemia protocols give 1/2 amp of D50 if the BG is between 50-70 mg/dl and a whole amp if < 50 mg/dl. Personally, I think this is a more reasonable approach. One experience that I remember is a patient getting an amp of D50 for a BG of 62 md/dl. A couple hours later he was in the low 100s. But about 8 hrs. later he was up at 500 mg/dl. I'm not sure if it was rebound hyperglycemia from all the dextrose, but I suspect that was a factor. Roxy