hypoglycemia med surg

Causes of hypoglycemia are often related to: - a mismatch in the timing of food intake -and the peak action of insulin or oral hypoglycemic agents that increase endogenous insulin secretion. -The balance between blood glucose and insulin can be disrupted by administering too much insulin or medication, ingesting too little food, delaying the time of eating, and performing unusual amounts of exercise. -Hypoglycemia can occur at any time, but most episodes occur when the OA or insulin is at its peak of action or when the patient's daily routine is disrupted without adequate adjustments in diet, medications, and activity. -Although hypoglycemia is more common with insulin therapy, it can occur with noninsulin injectable agents and OAs, and it may be severe and persist for an extended time because of the longer duration of action.

-Hypoglycemic symptoms may occur when a very high blood glucose level falls too rapidly (e.g., a blood glucose level of 300 mg/dL [16.7 mmol/L] falling quickly to 180 mg/dL [10 mmol/L]). -Although the blood glucose level is above normal by definition and measurement, the sudden metabolic shift can evoke hypoglycemic symptoms. -Too vigorous management of hyperglycemia with insulin can cause this type of situation.

Hypoglycemia, or low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood. -This causes the blood glucose level to drop to less than 70 mg/dL (3.9 mmol/L). - When plasma glucose drops below 70 mg/dL, counter-regulatory hormones are released and the autonomic nervous system is activated. -Suppression of insulin secretion and production of glucagon and epinephrine provide defense against hypoglycemia. -Epinephrine release causes manifestations that include: - shakiness, -palpitations, -nervousness, -diaphoresis, -anxiety, -hunger, and -pallor. -Because the brain requires a constant supply of glucose in sufficient quantities to function properly, hypoglycemia can affect mental functioning. *These manifestations are: - difficulty speaking, -visual disturbances, - stupor, -confusion, and - coma. *Manifestations of hypoglycemia can mimic alcohol intoxication. -Untreated hypoglycemia can progress to: -loss of consciousness, -seizures, -coma, and -death.

Hypoglycemic unawareness= is a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the glucose levels reach a critical point. -Then the person may become incoherent and combative or lose consciousness. This is often related to autonomic neuropathy of diabetes that interferes with the secretion of counter-regulatory hormones that produce these symptoms. Patients at risk for hypoglycemic unawareness include: those who have had repeated episodes of hypoglycemia, older patients, and patients who use β-adrenergic blockers. *Using intensive treatment to get tight blood glucose control in patients who are at risk for hypoglycemic unawareness may not be an appropriate goal because a major drawback is hypoglycemia. -These patients are usually managed with blood glucose goals that are somewhat higher than those of patients who are able to detect and manage the onset of hypoglycemia.

Hypoglycemia can usually be quickly reversed with effective treatment. -At the first sign of hypoglycemia, check the blood glucose if possible. If it is less than 70 mg/dL (3.9 mmol/L), immediately begin treatment for hypoglycemia. -If the blood glucose is greater than 70 mg/dL, investigate other possible causes of the signs and symptoms. - If the patient has manifestations of hypoglycemia and monitoring equipment is not available or the patient has a history of chronic poor glycemic control, hypoglycemia should be assumed and treatment initiated. *Follow the "Rule of 15" to treat hypoglycemia (Table 49-19). A blood glucose less than 70 mg/dL is treated by ingesting 15 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or a regular soft drink. -Commercial products such as gels or tablets containing specific amounts of glucose are convenient for carrying in a purse or pocket to be used in such situations. - Recheck the blood glucose 15 minutes later. If the value is still less than 70 mg/dL, ingest 15 g more of carbohydrate and recheck the blood glucose in 15 minutes. -If no significant improvement occurs after two or three doses of 15 g of simple carbohydrate, contact the health care provider. -Because of the potential for rebound hypoglycemia after an acute episode, have the patient ingest a complex carbohydrate after recovery to prevent another hypoglycemic attack. -Avoid treatment with carbohydrates that contain fat, such as candy bars, cookies, whole milk, and ice cream. -The fat in those foods will slow the absorption of the glucose and delay the response to treatment. - Avoid overtreatment with large quantities of quick-acting carbohydrates so that a rapid fluctuation to hyperglycemia does not occur.

In an acute care setting, patients with hypoglycemia may be treated with 20 to 50 mL of 50% dextrose IV push. -Another option, if the patient is not alert enough to swallow and no IV access is available, is to administer 1 mg of glucagon by intramuscular (IM) or subcutaneous injection. -An IM injection in a site such as the deltoid muscle will result in a quicker response. - Glucagon stimulates a strong hepatic response to convert glycogen to glucose and therefore makes glucose rapidly available. Nausea is a common reaction after glucagon injection. - Therefore, to prevent aspiration if vomiting occurs, turn the patient on the side until he or she becomes alert. -Patients with minimal glycogen stores will not respond to glucagon. This includes patients with alcohol-related hepatic disease, starvation, and adrenal insufficiency. -Teach family members and others likely to be present when a severe hypoglycemic episode occurs when to use and how to inject glucagon. Once the acute hypoglycemia has been reversed, explore with the patient the reasons why the situation developed. -This assessment may indicate the need for additional teaching of the patient and the family to avoid future episodes of hypoglycemia.