Hypoglycemia Protocol - Complete Dosage or Titrate to LOC?

Question#: 599

Question:

The 5.3 version of ALS PCS, Hypoglycaemia Protocol, has a line under the dosing charts for Dextrose, that states. “Titrate to level of consciousness, to the point the patient can consume complex carbohydrates.” What does the RPPEO wish us to do? Complete the dosage or titrate to LOC and at what point is the LOA considered enough to eat? Are we no longer re checking BGL post tx? Say LOA improves but BGL does not get above 4.0 mmol/l.

Answer:

Thank you for your MedicASK question.

As you mentioned, the standard states then when administering dextrose, we should “Titrate to level of consciousness, to the point the patient can consume complex carbohydrates.”

Practically, the goal is to titrate the medication over three (3) minutes, with a discontinuation in the event that your patient attains a level of consciousness where they can safely consume carbohydrates. What that might look like is not one single defining moment or sign/symptom, but rather a combination of your assessment and clinical judgment/decision making.

Titrating dextrose is a patient centered approach to dosing – it’s a balance of optimizing the therapeutic benefit, all while trying to avoid the adverse side effects. Ultimately, the goal is to avoid over treatment since this can result in rebound hyperglycemia, weight gain, micro and macro vascular complications, and severely impact the brittle patients. We should try and target relative normoglycemia.

As with any treatment that we administer, it’s important to monitor patients’ responses to said treatment, and in this case, that would include a repeat BGL. This is also in line with the Patient Assessment Standards.

Furthermore, education regarding meals and snacks should be had with the patient and their caregivers. The 15-15 rule is generally a good rule of thumb to follow in the hypoglycemic conscious patients: consume 15 grams of carbs, and re-assess after 15 minutes. Evidence suggests that 15 g glucose is required to produce an increase in BG of approximately 2.1 mmol/L within 20 minutes. Examples of 15 g of carbs would be 3 packets of sugar dissolved in water, 5 sugar cubes, 150 mL of juice or a soft drink, 6 LifeSaver candies, or 15 mL of honey.

If a patient still has uncorrected hypoglycemia, after your treatment, if would be prudent to initiate transportation to the hospital for a more thorough medical workup. While diabetes is usually the main cause of hypoglycemia, there are other causes on the differential that need to be investigated, such as, drugs, hepatic/renal/cardiac failure, hormone deficiencies, nonislet cell tumors, endogenous hyperinsulinism, or other accidental/malicious hypoglycemia.

Hope this helps.

Thank you again for your question, and stay safe out there

References

*ALS PCS 5.3 Companion Document
*BLS PCS
*Diabetes Canada, 2018. Clinical Practice Guidelines. http://guidelines.diabetes.ca/cpg
*Ontario Base Hospital Group Education Subcommittee, 2022. Hypoglycemia Review.
*Vella, A., 2022. Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, diagnosis, and causes. UpToDate, accessed 03 June 2022.