Diabetes - Hypoglycaemia Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The assessment and management of adults age 18+ with diabetes with hypoglycaemia

This guidance does not cover:

  • Diabetes in children and adolescents
  • Maturity onset diabetes of the young (MODY) and neonatal diabetes
  • Population screening for asymptomatic diabetes

Assessment

Hypoglycaemia is defined as:
  • blood glucose level less than 4 mmol/l; however hypoglycaemia symptoms can occur at a higher blood glucose level in those with newlly diagnosed diabetes who glocose levels are being lowered
Clinical judgement is as important as a blood glucose reading.
  • If left untreated, hypoglycaemia can lead to permanent brain damage and may even prove fatal.
Hypoglycaemia occurs when:
  • Inadequate carbohydrate intake; fasting, delayed or missed meals
  • Excessive physical activity
  • Insulin or other hypoglycaemic treatments i.e sulfonylurea
  • Excessive or chronic alcohol
  • Problems with insulin injection technique/site causing variable insulin absorption

Any person who is having a seizure or whose level of consciousness is reduced should have hypoglycaemia excluded.- Prompt treatment is required

Signs and Symptoms

  • Sweating and clammy skin
  • Dizziness and light-headedness
  • Irritability and confusion
  • Hunger
  • Blurred vision
  • Headache
  • Tingling or numbness in lips or tongue
  • Shakiness
  • Loss of coordination
  • Heart palpitations

Red Flags

Seek immediate or urgent specialist advice/treatment if:

Severe Hypoglycaemia

  • The patients should be given glucagon injection and blood glucose levels checked after 10 minutes.
  • The patient may wake up once blood glucose level is returning to normal
  • If a relative or carer is not available to give glucagon, then a paramedic ambulance should be called to treat and manage the hypoglycaemia
  • If the patient does not respond to emergency treatment, transfer immediately to A&E

Investigations

Search for cause of Hypoglycaemia which include:

  • Accidental or intentional excessive insulin
  • Reduced calorie intake or malabsorption
  • Excessive exercise
  • Infection with anorexia
  • Vomiting
  • Increased insulin sensitivity with weight loss
  • Drugs including sensitivity e.g. biguanides and glitazones
  • Beta blockers
  • Alcohol
  • Renal failure
  • Adrenal insufficiency

Management

Management of hypoglycaemia
  • People experiencing hypoglycaemia require quick acting carbohydrate to return their blood glucose levels to normal and should be treated promptly and without delay
  • Where it is safe to do so, a blood glucose measurement should be taken to confirm hypoglycaemia
  • If measurement is difficult, e.g. in a patient undergoing a seizure then treatment should not be delayed
  • Adults who are experiencing hypoglycaemia symptoms and have blood glucose lower than 4.0mmol should be treated with 15 – 20g of a short acting carbohydrate such as:
    • 100 – 120mls of Lucozade
    • 200mls of a non-diet drink
    • 4-5 glucose tablets
    • 4-5 jelly babies
    • 200mls of fruit juice
  • Re-check blood glucose level after 10 - 15 minutes later – if it is still less than 4.0mmol/l repeat step above up to three times.
  • Adults who are experiencing hypoglycaemia symptoms but have blood glucose greater than 4.0mmol/l treat with a carbohydrate snack only.
Follow on Treatment
  • To prevent blood glucose levels from dropping again, follow sugary foods with 10 – 20g of a longer acting carbohydrate such as :
    • Half a sandwich
    • A piece of fruit
    • A small bowl of cereal
    • Biscuits and milk
    • The next meal if due
    • Ensure the blood glucose is monitored regularly for 24 – 48 hours
Severe Hypoglycaemia
  • If the hypoglycaemia episode is more severe and the patient cannot treat themselves:
    • Apply Glucogel (or treacle, jam or honey) on the inside of the patients cheeks and gently massage the outside of the cheeks
    • If unconscious Call an ambulance immediately – Glucagon can be injected if the person treating has been trained to use it.
Important
  • If unable to swallow or is unconscious do not give anything by mouth.
  • Make sure family and friends are aware of this
  • If unconscious, place the patient in the recovery position
  • Patients experiencing regular episodes of hypoglycaemia require prompt review by the diabetes team
  • Severe episode of hypoglycaemia require urgent review by the diabetes team.
  • Hypoglycaemia is a common side effect of insulin treatments and is also associated with the use of sulfonylureas.
  • Hypoglycaemia is a significant cause of morbidity and mortality in patients with diabetes.
Patients should be advised to:
  • Recognise the symptoms of hypoglycaemia
  • Keep a drink containing glucose, glucose tablets, jelly babies for when hypoglycaemia signs or symptoms appear
  • Notify patients who drive that they must refer to the 'At a Glance Guide' about when they should report diabetes –related complications to the Driver and Vehicle Licensing Agency (DVLA).
  • Ensure that patients know when and how to test their blood glucose levels when driving and to keep a snack in the car
  • Advice on operating machinery and information to provide to colleagues
  • Advice regarding pregnancy and contraception

Referral

Referral Criteria

  • Refer to Diabetes Specialist Team who will contact the patient or the patients GP
    • Adults with diabetes who have experienced hypoglycaemia requiring medical attention
    • Adults with diabetes who are experiencing frequent episodes of hypoglycaemia
  • The Yorkshire ambulance service will refer all patients who they have attended for a hypoglycaemia episode to the Diabetes Specialist Team.
  • The Diabetes Specialist team will review the patient and their current treatment and they will be provided with support and education regarding the management of hypoglycaemia

Referral Instructions

  • e-consultation is available for diabetes for both the Consultant Diabetologists and the Diabetes Specialist Nurses
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made to the Diabetes Specialist team via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 02.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 03.2017
  • Publication Date: 05.2017
  • Review Date: 02.2019
  • Ref No: END3 - 02.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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