Questions, problems, and issues that confront my patients on a daily basis often inspire my blogs. Hypoglycemia is on everyone's list of concerns during a visit. Unfortunately, unintended low blood sugars are here to stay until a true artificial pancreas is developed in which a glucose sensor is "married" to an insulin pump. In this scenario, the sensor will provide information to the pump continuously and insulin will be given (or not) appropriately. We are not there yet; so we need to make do with options that are available now. These include blood glucose meters, continuous glucose sensors, monitors for sounds (baby monitors etc.), and hypoglycemia trained animals.
Firstly, let's define hypoglycemia. We all talk about it and each of you has experienced a hypoglycemic episode. In general, most diabetes experts define hypoglycemia as blood sugars less than 70 mg/dl. However, it is important to realize that in smaller children and infants, lows may be considered to be less than 80 mg/dl. Keep in mind that you may or may not experience symptoms of hypoglycemia (see following) with a low blood sugar (even less than 50 mg/dl). People that have difficulty knowing that they are low have hypoglycemic unawareness, a condition that may occur after many years of diabetes.
It also is important to understand mild, moderate, and severe hypoglycemia to know how to treat the symptoms appropriately. In situations with mild hypoglycemia, you start to feel sweaty, shaky, and very hungry. Your body is attempting to release hormones (epinephrine and glucagon) to raise blood sugar. Your body is talking to you: listen! Test your blood sugar and consume carbohydrate.
In moderate hypoglycemia, you start to feel dizzy, a bit out of it, develop mood and behavior changes, and maybe lose focus. This is called neuroglycopenia (low blood sugars affecting your brain) and must be taken seriously. In these situations you can still test blood sugars and consume carbohydrate. It is important that you do so quickly before the hypoglycemic episode becomes severe and you develop hypoglycemia associated with major brain disturbance.
Examples of severe neuroglycopenia include seizures and loss of consciousness. In these scary situations, someone else will need to come to your assistance and give you carbohydrate (by glucose paste or cake mate if you can swallow), glucagon, or glucose by vein. Your family or trained school personnel will be ready to assist with either glucose paste or glucagon. The Emergency Medical Transport team (911) is usually called in these situations to take vital signs and in some cases, administer IV glucose. A trip to the hospital for observation sometimes occurs. The goal, of course, is to avoid moderate and severe hypoglycemia as much as possible.
How can we minimize episodes of hypoglycemia in the era of intensive insulin therapy? How do you walk the fine line between tight glucose control and hypoglycemia? Answer: you do the best you can!
