Hypoglycemia

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Patients with or without diabetes may experience hypoglycemia in the hospital due to co-morbidities such as heart failure, renal or liver disease, malignancy, infection or sepsis or in association with an altered nutritional state. Additional triggering events include sudden reduction of corticosteroid dose, altered ability of the patient to report symptoms, reduced oral intake, emesis, new "nothing by mouth" (NPO) status, inappropriate timing of short- or rapid-acting insulin in relation to meals, and unexpected interruption of enteral feedings or parenteral nutrition (American Diabetes Association (ADA) 2015; CDA, Houlden, Capes, Clement, Miller 2013; Rubin & Golden 2013).

Patients with diabetes are at a higher risk of hypoglycemia than other patients due to the added risk of medication errors involving insulin (Rubin & Golden 2013). Hypoglycemia is associated with increased length of stay and inpatient mortality (Nirantharakumar et al. 2012). In patients with type 2 diabetes and established cardiovascular disease (or very high risk for cardiovascular disease), symptomatic hypoglycemia (<2.8 mmol/L) is associated with increased mortality (CDA, Clayton, Woo, Yale 2013).

Symptoms of hypoglycemia are sweating, shakiness, tachycardia, anxiety, hunger, weakness, fatigue, dizziness, difficulty concentrating, confusion and blurred vision. In extreme cases, hypoglycemia may lead to coma and death (Desimone & Weinstock 2016). The Canadian Diabetes Association (CDA, Clayton, Woo, Yale 2013) lists the symptoms of hypoglycemia according to neurogenic (autonomic) and neuroglycopenic symptoms (see Table 1 below).

Symptoms of hypoglycemia

• Neurogenic (autonomic)

  • Trembling

  • Palpitations

  • Sweating

  • Anxiety

  • Hunger

  • Nausea

  • Tingling

• Neuroglycopenic

  • Difficulty concentrating

  • Confusion

  • Weakness

  • Drowsiness

  • Vision changes

  • Difficulty speaking

  • Headache

  • Dizziness

Hypoglycemia with diabetes mellitus, type 1 or type 2

Insulin is the most appropriate agent for effectively controlling glycemia in-hospital (CDA, Houlden, Capes, Clement, Miller 2013). However, insulin causes the most harm and severe adverse events of the high alert medications (CDA, Houlden, Capes, Clement, Miller 2013; ISMP 2016). Mild hypoglycemic events are common in medical and surgical patients with type 2 diabetes who are receiving subcutaneous insulin therapy. Increasing age, impaired renal function, daily insulin dose, and insulin regimen (basal/bolus versus SSI) are important predictors of hypoglycemia in patients with type 2 diabetes mellitus who are on insulin therapy (Farrokhi et al. 2012).

Nondiabetic hypoglycemic coma and drug-induced hypoglycemia without coma

Hypoglycemia is uncommon in patients who do not have diabetes. Drugs are the most common cause of nondiabetic hypoglycemia. Other causes are malnutrition and alcohol use. Hypoglycemia may also follow bariatric surgery.

Drugs that may lead to hypoglycemia include: Bactrim (sulfamethoxazole and trimethoprim), beta-blockers, haloperidol, MAO (monoamine oxidase) inhibitors, pentamidine, quinidine, quinine, ACE (angiotensin-converting enzyme) inhibitors, lithium and second generation antipsychotic agents as well as medications used in the treatment of diabetes, such as insulin or oral medications used for management of type 2 diabetes (Cryer 2011; Desimone & Weinstock 2016; Murad et al., 2009; Suzuki et al. 2009). Hypoglycemia secondary to these drugs is higher in elderly patients and in patients with sepsis, and renal or hepatic disease (Murad et al. 2009).

Importance to Patients and Families

Hypoglycemia causes tremor, anxiety, sweats and cognitive impairment. Recurrent hypoglycemia may impair the individual's ability to sense subsequent hypoglycemia (CDA, Clayton, Woo, Yale, 2013). In severe cases it may be fatal, although inpatient hypoglycemia is usually nonfatal (Rubin & Golden, 2013). Patients and families can play an important role in reducing errors and harm to the patient by understanding the medications the patient is taking, what each medication is for and when it should be taken and the dosage.

Success Stories

Insulin safety is a key priority nationally for healthcare organizations, the Institute for Safe Medication Practice (ISMP) Canada and provincial governments. There is a growing interest in the adoption of insulin pens in the hospital setting as a means to improve insulin administration safety and ensure continuity of insulin product use by the patient from the community to the hospital setting and at discharge.

The Pharmacy leaders at the University Health Network (UHN) and Hamilton Health Sciences (HHS) agreed to collaborate for insulin pen implementation in 2013, as both organizations were undertaking conversion to insulin pens at one or more of their sites. The knowledge gained from this project led to the development of a toolkit to provide guidance and stewardship to other healthcare organizations in the safe implementation of insulin pen use in a variety of adult patient care settings.

The collaboration examined the following:

• To evaluate the effectiveness of the toolkit tools in the safe conversion to insulin pens on selected patient care areas at HHS and UHN.

• To evaluate outcome measures related to insulin administration to further inform healthcare organizations.

• To evaluate the work flow and workload changes related to conversion from insulin vials and syringes.

• To facilitate knowledge translation principles of synthesis, dissemination, exchange and application of knowledge to improve health services.

• To evaluate outcome measures related to insulin administration.

• To capture lessons learned for the benefit of other healthcare organizations.

• To develop a best practice education and implementation plan for replication by other healthcare organizations across the country.

In order to help other organizations embark on the shift in clinical practice to use of insulin pens, UHN and HHS have developed a toolkit within the framework of five guiding dimensions of what is required to successfully achieve such a practice change. This framework is supplemented, in a series of appended documents, with checklists designed as considerations for healthcare organizations to take into account as they contemplate this clinical practice change.

The framework offered in the toolkit captures the essence of the UHN and HHS experience and is offered from an evidence based perspective as an essential component for successful adoption of clinical practice changes related to insulin administration. (Health Standards Organization, 2015)