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• this situation occurs most often in patients who have had months (or
longer) of hyperglycemia (plasma glucose levels >200 mg/dL
[11.1mmol/L] at all times) whose plasma glucose levels are then
lowered by medication or lifestyle changes closer to the normal
range.
• Hyperadrenergic hypoglycemic symptoms can occur when the
plasma glucose level in these patients is 120 mg/dL (6.7 mmol/L) or
even higher.
• If these patients continue to keep their plasma glucose level
substantially less than 200 mg/dL (11.1 mmol/L), the threshold at
which they manifest hypoglycemic symptoms will fall to more typical
levels (<70 mg/dL [3.9mmol/L]).
Reactive or postprandial hypoglycemia :
develops in response to a nutrient challenge. see it in some
post-GI surgical patients, when gastric contents get dumped into
the small intestine too quickly.
Ending the fast: Three steps are performed at the end of the
fast:
1) Collect samples for plasma glucose, insulin, C-peptide,
proinsulin, BHOB, and oral hypoglycemic agents
2) 1 mg of glucagon is given intravenously and the plasma
glucose measured 10, 20, and 30 minutes later
3) The patient is fed
Laboratory tests
1) CBC
2) Glucose
3) Insulin
4) C-peptide
5) Beta-hydroxybutyrate
6) Proinsulin
7) Antibodies for insulin and its receptors
8) Sulfonylurea and meglitinide screen
9) Electrolytes, BUN/Cr, UA
10) liver function tests, cortisol and thyroid levels , growth
hormone level
11) Other tests: ECHO, ECG, CXR , CT and MRI
Management of Hypoglycemia
The management of hypoglycaemia can be divided into three
phases:
In the UK, it has been recommended that ‘four is the floor’ for
blood glucose targets in order to limit hypoglycaemia frequency.
For non critically ill patients, glycemic goals are premeal and
random blood glucose levels <140 mg/dl and<180 mg/dl
respectively
If the glucose is low (<55 mg/dL) and the patient is a not a diabetic,
draw blood for glucose, insulin, C-peptide, and an oral hypoglycemic
agent screen and then treat
PATIENT-CONSIDERATIONS-Discharge-Criteria
1. Normoglycemia and risk of severe hypoglycemia is
negligible.
Differential Diagnosis
• Drug/alcohol intoxication
• Psychosis, depression
Complications
1-recurrent/persistent psychosocial morbidity(Emotional liability ,
irritability, depression).
3-Seizure
5-Coma
6-Death
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