1. Hypoglycaemia is a blood glucose
level of below 4 mmol/l.
4 is the floor

2. Mags Bannister Diabetes Nurse Consultant
Hypoglycaemia
Mags Bannister
Diabetes Nurse Consultant

3. What happens now in clinical practice re hypo’s?

4. Mild Hypoglycaemia Sweating Dizziness Trembling
Tingling hands,feet,lips or tongue
Hunger
Blurred vision
Difficulty in concentration
Palpitations
Occasional headaches

5. Causes of hypoglycaemia
Too much insulin/sulphonylurea 
Extra activity e.g. shopping, DIY, gardening, sexual activity or sport 
Insufficient food  (particularly CHO’s)
Delayed or missed meal 
Poor injection technique/change of site 
Change of routine 
Alcohol
Heat - hot weather/sauna/hot bath

6. Autonomic Neuroglycopenic Malaise
Sweating Palpitations Shaking Hunger
Confusion
Drowsiness
Speech difficulty
In coordination
Atypical behaviour
Diplopia (double vision)
Nausea
Headache

7. Severe Neuroglycopenia
Mild Neuroglycopenia
Cognitive dysfunction
Blood glucose level
Autonomic activation
Release of counter Regulation Hormones
Sweating
Tremor
Palpitations
Blurred vision
Severe Neuroglycopenia
Unconsciousness/Coma
Aggression
Staggering
Death

8. Mild “hypo” - treatment
6-7 Dextrose tablets
Glucochek
6 sugar lumps
4 teaspoons of sugar
100mls Lucozade
grams rapid acting CHO
Eat next meal if due OR
Have a snack, e.g. banana/bread /biscuits etc
Ref The hospital management of hypoglycaemia in adults with diabetes mellitus 2010

9. SEVERE HYPOGLYCAMIA Requires third party assistance
Odd behaviour e.g. rudeness/laughter (appear to be drunk when not)
Aggressive behaviour
Confusion
UNCONSCIOUS

10. Severe hypo glycaemia Take immediate action EAT NEXT MEAL if due OR
Glucose in liquid form
LUCOZADE min 100mls
lemonade/cola/ribena- 200mls
EAT NEXT MEAL if due OR
TAKE A SNACK

11. If unable to take anything orally
999
Give GLUCAGON injection - I.M
(can take 15mins to take effect) OR
I.V. Dextrose
150mls 10% or
75mls 20%
If necessary repeat
Ref The hospital management of hypoglycaemia in adults with diabetes mellitus 2010
Re-check blood glucose in 10 minutes after IV glucose if still below 4mmols repeat
When blood glucose above 4.0mmls give long acting carbohydrate
Monitor blood glucose levels

12. Which Patients with Diabetes are at Risk of Hypoglycaemia
TYPE 1
ALL
Type 2
If treated with a sulphonyurea ( gliclazide or glimepiride)
If treated with Insulin
If treated with a combination that includes either or both or the above

13. Prevention
Ensure Staff understand the mode of action of the treatment prescribed
Discuss timing & dose of oral therapy/insulin
Educate Staff how to
prevent/recognise hypo symptoms

14. Prevention
Ensure patients are aware of the correct/safe treatment of hypos
Discuss the acceptable blood glucose
levels for the individual patients needs
Maintain good glycaemia control without compromising patient safety

15. Hyperglycaemia and illness management

16. High Blood glucose levels
What blood glucose levels cause concern? What would you do if a patients blood glucose levels were running high?

17. Illness Infection Steroids Stress High Blood glucose levels
Poor appetite
Poor fluid intake

18. Steroid treatment
Fasting blood glucose levels will often be within normal range 5-10mmols/l
Pre-tea and bed time readings can be >20mmols/l
Blood glucose levels rapidly increase
Insulin maybe need when on steroid treatment but not at any other time

19. DIABETIC KETOACIDOSIS Type 1 DM
A state of severe, uncontrolled diabetes due to insulin deficiency and increased counter regulatory hormones.
High blood glucose levels (PG>11 mmol/l
Moderate ketonuria (3mmol/L or over 2+on urine stick)
Acidosis (arterial pH<7.30 & serum bicarb< 15mmol/L.)
Usually Type 1
Ref: The management of Diabetic Ketoacidosis in adults
NHS Diabetes 2010

20. DKA Lack of insulin Reduced glucose uptake
Increased liver glucose output
Breakdown of fat
Hyperglycaemia
Ketosis
Glycosuria
Reduced pH, vomiting,
ketonuria, hyperventilation
Osmotic diuresis
Loss of water, change in electrolytes
Dehydration
Electrolyte imbalance, acidosis
Tachycardia, hypotension
Impaired consciousness, coma

21. Hyperosmolar Hyperglycaemic State HHS Type 2 DM
Severe hyperglycaemia (PG>33.3 mmol/L)
Profound dehydration (-10L)
No ketosis/acidosis (pH>7.3)
Middle-aged/elderly
Insidious onset (days/weeks)
Often undiagnosed Type 2
Mortality %

22. HHS Lack of insulin Reduced glucose uptake
Increased liver glucose output
Hyperglycaemia
Glycosuria
Osmotic diuresis
Loss of water, change in electrolytes
Dehydration
Tachycardia, hypotension

23. HYPERGLYCAEMIA – Sick Day Rules
Never stop taking insulin or tablets (metformin and SGLT2i should be omitted if dehydration a risk)
Monitor more often
Type 1 – test Urine or Blood for ketones
Encourage more Fluids (sugar free)
Rest
Vomiting – if accompanied by rapid deep breathing + drowsiness – dial 999
If BG persistently raised – insulin dose may be increased temporarily

24. If unable to eat - replace solid food with alternatives such as
Amount
CHO content
Soup (thickened or creamed)
200mls
15grams
Milk
10 grams
Pure fruit juice
100mls
Lucozade
60mls
Build up/ Complan
1/3rd serving
Milk pudding /Custard
75g or ½ pot

25. Accessing Advice
Diabetes Specialist Nursing team Horton Park Centre Monday to Friday and Emergency on call am and 5.30pm- 9pm Saturday and Sunday and Bank Holidays 7.30am -9pm

26. Information needed when ringing DSN
Patients name , DOB and NHS number
Current treatment
Type of diabetes
Blood glucose levels
Ketones level if indicated
Any signs of illness/infection

27. Questions