Diabetes Outreach Network
QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Chapter 18
Acute Complications of Diabetes: Hypoglycemia and Hyperglycemia

Hypoglycemia is often defined as plasma blood glucose levels lower than approximately 72 mg/dl. Hypoglycemic episodes can vary greatly in severity of symptoms.

Diagnostic Criteria

Signs/ Symptoms	Mild: sweating, trembling, difficulty concentrating, lightheadedness, lack of coordination Severe: inability to self-treat due to mental confusion, lethargy or unconsciousness.
Causes	Too much diabetes meds/insulin Too much activity Not eating enough carbohydrate Drinking too much alcohol Advancing age and poor nutrition
Treatment	Mild hypoglycemia: 15/15 rule Check blood glucose (BG) If BG is 50-69: give 15 grams carbohydrate If BG is <50: give 30 grams carbohydrate Wait 15 minutes and recheck BG If BG < 70, repeat step 1 If BG > 70, monitor for signs/symptoms of low BG. (May need to eat an additional snack if next meal is more than 1 hour away). Severe hypoglycemia: If able to swallow without risk of aspiration, offer juice or non-diet soft drink or place glucose gel, honey, syrup or jelly inside the person’s cheek. If unable to swallow without risk of aspiration: give glucagon injection. Recommended doses are: .. older children and adults: 1 mg .. children under age 5: 0.5 mg infants: 0.25 mg

Examples of 15 grams of carbohydrate include 3 glucose tablets, 8 Lifesavers®, 2 Tbsp raisins, 4 oz non-diet soft drinks, 4 oz fruit juice or 8 oz nonfat milk. It is best to avoid food high in fat content as they may slow gastric emptying and absorption of carbohydrate, taking longer to raise blood glucose levels.

Hyperglycemia

Signs/ Symptoms	Increased thirst, increased urination, excessive hunger, blurred vision, weight loss (related to lack of insulin). Weakness, lethargy, malaise and headache. Nausea, vomiting, fruity breath, and abdominal pain (related to ketosis). Difficulty breathing (related to the metabolic acidosis).
Causes	Not enough diabetes meds/insulin or physical activity Eating too much carbohydrate Stress
Treatment	Treatment Fluids (caffeine free and carbohydrate/calorie free) Check ketones Insulin to correct hyperglycemia for some

Prolonged hyperglycemia can lead to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), both of which are life threatening. DKA is a complication that results from the lack of insulin and is most frequently seen in those with type 1 diabetes. It is characterized by hyperglycemia, ketosis, acidosis, dehydration and electrolyte imbalance.

HHS is most frequently seen in older adults with type 2 diabetes. It is similar to DKA except that insulin deficiency is not as prevalent. It is characterized by severe hyperglycemia, absence of significant ketones, profound dehydration and mental status changes.

Comparison of DKA and HHS Features

Feature	DKA	HHS
Age	Under 40 years of age	Over 60 years of age
Duration of symptoms	Less than 2 days	More than 5 days
Plasma BG level	< 600 mg/dl	> 600 mg/dl
Sodium concentration	Normal or low	Normal or high
Bicarbonate concentration	Low	Normal
Ketone bodies	4 +	Less than 2+
Arterial pH	Low	Normal
Serum osmolality	< 320 mOsm/kg	>320 mOsm/kg
Prognosis	3-10% mortality	10-20% mortality
Priorities of Treatment	1. Provide insulin 2. Correct fluid/electrolyte imbalances	1. Fluid/electrolyte replacement 2. Adequate insulin

References:
Franz MJ et al. (2003). A Core Curriculum for Diabetes Educators, 5th Ed., Diabetes Complications. American Association of Diabetes Educators, Chicago.