HYPOGLYCAEMIA

Patient is conscious, oriented and able to swallow

• Step 1: If patient has insulin infusion in situ, stop it
• Step 2: Give glucose 4–5 tablets or 60 mL of Lift (fast acting glucose) juice or 150-200 ml of pure fruit juice (do not use if following low potassium diet)
• 15 min later, repeat capillary glucose, if still <4 mmol/L then repeat step 2
• Step 3: If, after 45 min or 3 cycles of step 2, capillary glucose remains <4 mmol/L, consider IV access to give 100 ml of 20% glucose or 200 ml of 10% glucose over 15 min
• Step 4: After 10 min, repeat capillary glucose, if still < 4mmol/L, repeat step 2

When capillary blood glucose > 4 mmol/L

• Step 5: Give, if due, normal meal (must contain carbohydrate) or long acting carbohydrate snack (20g) e.g. include 2 biscuits or one slice of bread/toast or 200-300ml of milk (not soya or other alternative milk)
• Step 6: Do not omit next insulin injection

Patient is semi-conscious (gag reflex present and swallowing deemed to be safe)

• Step1: If patient has insulin infusion in situ, stop it
• Step 2: Give glucose oral gel (e.g. GlucoGel^®) 1 or 2 tubes (each 25 g contains 10 g glucose) oral-squeezed into mouth between teeth & gum
• 15 min later, repeat capillary glucose, if still <4 mmol/L then repeat step 2
• Step 3: If, after 45 min or 3 cycles of step 2, capillary glucose remains <4 mmol/L, consider IV access to give 100 ml of 20% glucose or 200 ml of 10% glucose over 15 min
• Step 4: After 10 min, repeat capillary glucose, if still < 4mmol/L, repeat step 2 

When capillary blood glucose > 4 mmol/L

• Step 5: Give, if due, normal meal (must contain carbohydrate) or long-acting carbohydrate snack (20g) e.g. include 2 biscuits or one slice of bread/toast or 200-300ml of milk (not soya or other alternative milk)
• Step 6: Do not omit next insulin injection

Patient unconscious or having seizure or very aggressive or remains nil by mouth

• Step 1: Check ABCDE (airway, breathing, circulation, disability & exposure)
• Step 2: If patient has insulin infusion in situ, stop it
• Step 3: Give 100 mL glucose 20% or 200 mL glucose 10% IV into large vein through Venflon (largest gauge you can insert) over 15 min and flush with sodium chloride 0.9% 10 mL
• in exceptional circumstances where securing IV access is difficult or delayed, use glucagon 1 mg IM
• Glucagon is only licensed for insulin induced hypoglycaemia
• delayed response in sulfonylurea induced hypoglycaemia (may take up to 15 min to take effect)
• less effective in patients who are chronically malnourished (including those with prolong starvation or in patients with alcohol dependency or with chronic liver disease due to depleted glycogen storage in liver)
• Step 4: 10 min later, repeat capillary glucose. If < 4 mmol/l, repeat step 3

When capillary blood glucose > 4 mmol/L & patient can swallow

• Step 5: Give, if due, normal meal (must contain carbohydrate) or long-acting carbohydrate snack (20g) e.g. include 2 biscuits or one slice of bread/toast or 200-300ml of milk (not soya or other alternative milk)
• if patient given glucagon, give larger portion of carbohydrate snack (40g) to replenish glycogen stores
• Step 6: Do not omit next insulin injection

Maintenance IV infusion of glucose

• If hypoglycaemia induced by excess oral agents or overdose of insulin or patient remains nil by mouth, consider maintenance IV infusion of glucose 10% at 100 mL/hr

Patient is an adult requiring enteral feeding

• Step 1: If patient has insulin infusion in situ, stop it.
• Step 2: Administer via feed tube 15–20 g quick acting carbohydrate e.g. 50–70 mL of Fortijuice^® (not Fortisip^®), 60 ml of Lift (fast acting glucose) juice or 150-200 ml of orange juice (do not use if following low potassium diet)
• follow treatment by water flush of the feeding tube to prevent blockage
• do not administer these treatments via IV line or TPN line
• Step 3: 15 min later, repeat capillary glucose, if still <4 mmol/L, repeat step 2
• Step 4: If, after 45 min or 3 cycles of step 2, capillary glucose remains <4 mmol/L, consider IV access to give 100ml of 20% glucose or 200ml of 10% glucose over 15 min

When capillary blood glucose > 4 mmol/L & patient has recovered

• Step 5: Restart feed and start 10% glucose at 100 ml/hr
• Step 6: Do not omit insulin injection if due