Hypoglycemia, also known as hypoglycemia or hypoglycemic syndrome, is a clinical syndrome characterized by low plasma (or serum) glucose levels, resulting from a variety of causes, and associated symptoms and signs. Patients often experience palpitations, anxiety, tremors, and, in severe cases, coma. In most patients, plasma glucose concentrations gradually increase with prompt glucose supplementation, and symptoms and signs resolve. Repeated, severe, and prolonged episodes of hypoglycemia can cause irreversible brain damage and require prompt prevention and treatment.

Clinical classification

1. Classification based on the relationship between hypoglycemia and eating

(1) Fasting hypoglycemia: Hypoglycemia occurs in the fasting state (gastrointestinal absorption interval), also known as post-absorptive hypoglycemia. Clinically, it is most common due to alcohol and drug use.

(2) Postprandial hypoglycemia: It is more common in emotionally unstable or neurotic women, often triggered by mental stimulation or anxiety, and often accompanied by gastrointestinal dysfunction. It usually occurs 1.5 to 3 hours after breakfast, and less often after lunch and dinner. Although it recurs repeatedly, the condition does not worsen.

2. Classification based on the patient’s clinical manifestations

(1) Mild: Autonomic nervous system symptoms occur and patients can handle them on their own.

(2) Moderate: Autonomic nervous system symptoms and neurotic hypoglycemia symptoms occur, and patients can handle them on their own.

(3) Severe: Blood glucose concentration <2.8mmol/L (<50mg/dl), loss of consciousness may occur, and assistance from others is required for treatment.

Epidemiology

Contagious

Not contagious.

Incidence

Hypoglycemia is a common symptom in diabetic patients. Most patients with type 1 diabetes will experience hypoglycemia, while the incidence of hypoglycemia in patients with type 2 diabetes is lower than that in patients with type 1 diabetes.

High-risk population

This disease is more common in patients with diabetes, patients with congenital enzyme metabolism abnormalities, young women, and newborns.

Causes

Overview

Hypoglycemia can occur in both non-diabetic and diabetic patients. Its etiology is complex, with medications being the most common cause. Additionally, liver failure, nutritional deficiencies, beta-cell tumors, and congenital hyperinsulinemia can also contribute.

Basic cause

1. Medication

(1) Hypoglycemia rarely occurs in non-diabetic people. It may be caused by a variety of drugs such as quinolones, pentamidine, quinine, beta-blockers, and angiotensin-converting enzyme inhibitors.

(2) Hypoglycemia in diabetic patients is mainly caused during the treatment process. Exogenous insulin and drugs that stimulate endogenous insulin secretion, such as glibenclamide, gliclazide, and glipizide, will stimulate increased glucose utilization. If used improperly, they may cause hypoglycemia, or even severe or fatal hypoglycemia.

2. Disease

(1) Non-insulin-mediated hypoglycemia is common in patients with critical illnesses, such as liver failure, renal failure, heart failure, sepsis, or malnutrition. It is associated with the corresponding suppression of endogenous insulin synthesis caused by non-islet cell tumors, and adrenocortical insufficiency or hypopituitarism, resulting in insufficient secretion of hormones that counteract insulin.

(2) Insulin-mediated hypoglycemia is also known as endogenous hyperinsulinemia. When the plasma glucose concentration drops to a hypoglycemic level and the insulin secretion rate cannot decrease accordingly, hyperinsulinemic hypoglycemia occurs. Causes of hypoglycemia caused by endogenous hyperinsulinemia include β-cell tumors, β-cell functional diseases, insulin autoimmune hypoglycemia, and increased endogenous insulin caused by taking β-cell secretagogues.

3. Genetics

The most common cause of persistent hypoglycemia in infants is persistent hyperinsulinemic hypoglycemia of infancy (PHHI), or congenital hyperinsulinemia. PHHI is a genetic disorder characterized by dysregulation of insulin secretion.

Risk factors

1. Diabetes

Insulin or drugs with similar hypoglycemic effects are required in the treatment of diabetes. Overdose, inappropriate administration time, wrong dosage form, etc. may lead to lower blood sugar and increase the risk of hypoglycemia.

2. Poor eating habits

Poor eating habits, such as not eating normally and fasting overnight, can lead to reduced or delayed exogenous glucose intake, making hypoglycemia more likely to occur.

3. Overwork

Excessive exertion, such as long-term running or mountain climbing, will lead to increased glucose utilization, a decrease in blood sugar levels in the body, and the risk of hypoglycemia.

4. Drinking a lot of alcohol

Drinking large amounts of alcohol can lead to a decrease in endogenous glucose production, making hypoglycemia more likely to occur.

symptom

Overview

Symptoms of hypoglycemia primarily include autonomic and cerebral hypoglycemia. Patients often experience palpitations, sweating, tremors, and, in severe cases, altered mental status. Prolonged, severe hypoglycemia (approximately >6 hours) can cause loss of consciousness, permanent neurological damage, and even death.

Typical symptoms

1. Symptoms of autonomic hypoglycemia

Patients often experience tremors, palpitations, and anxiety, as well as sweating, hunger, and paresthesias. These symptoms are largely due to sympathetic nervous system activation rather than adrenal medullary activation.

2. Symptoms of hypoglycemia in brain neurons

Lack of glucose in the brain often manifests as cognitive impairment, behavioral changes, psychomotor abnormalities, and, at even lower blood glucose levels, seizures and coma.

Associated symptoms

Hypoglycemia is rarely associated with symptoms. Certain specific causes of hypoglycemia may have characteristic symptoms. For example, glycogen storage disease can cause liver enlargement, severe growth retardation, muscle atrophy, and inability to walk independently. Cirrhosis can cause ascites, edema, decreased appetite, and jaundice.

complication

1. Cardiovascular disease

During hypoglycemia, the sympathetic chromaffin system is stimulated, leading to an accelerated heart rate or sinus tachycardia. However, a very small number of patients may also experience sinus bradycardia. Various other arrhythmias, such as atrial premature beats, supraventricular tachycardia, ventricular premature beats, and paroxysmal ventricular tachycardia, may also occur. Ventricular arrhythmias are generally considered a rare cause of death from hypoglycemia.

2. Brain diseases

If hypoglycemia cannot be relieved and the blood sugar concentration continues to drop for more than 6 hours, it can cause irreversible morphological changes in brain cells, such as congestion, multiple punctate hemorrhages, and brain tissue damage. If the correct diagnosis and treatment are not made in time, cerebral edema, ischemic punctate necrosis, encephalomalacia, dementia, coma, shock, and even death may occur.

3. Others

Diabetes may worsen, and ketosis may even occur. Repeated episodes of hypoglycemia can reduce awareness of hypoglycemia and even trigger acute respiratory distress syndrome.

examine

Scheduled inspection

Patients experiencing symptoms such as palpitations, anxiety, tremors, and psychomotor abnormalities should seek medical attention promptly. Upon seeing a doctor, the doctor will first conduct a physical examination to assess the patient’s general condition. The doctor will then check the patient’s blood sugar level. After making a preliminary assessment of the patient’s condition, the doctor may recommend plasma hormone measurements, drug plasma concentration tests, a fasting test, CT scans, MRI scans, and ultrasounds to identify the cause.

Physical examination

Physical examination shows that the patient is pale and sweating, with increased heart rate and systolic blood pressure, but the increase will not be large. Severe patients may show hypothermia, epileptic seizures, and even confusion.

Laboratory tests

1. Blood sugar

Blood glucose testing can reveal fasting blood glucose levels, which can help diagnose hypoglycemia. Fasting blood glucose levels in adults are typically below 2.8 mmol/L, and in people with diabetes, below 3.9 mmol/L.

2. Plasma-related hormone determination

To further investigate the etiology of hypoglycemia, it is necessary to simultaneously measure blood glucose, insulin, C-peptide, proinsulin, and β-hydroxybutyrate levels, as well as insulin autoantibodies, during spontaneous hypoglycemic episodes, and to observe the glycemic response to the injection of 1.0 mg of glucagon. These steps can help differentiate between endogenous and exogenous insulin-mediated hypoglycemia and potential etiologies.

3. Drug plasma concentration test

Check the plasma concentration of hypoglycemic drugs to determine whether hypoglycemia is caused by hypoglycemic drugs.

4. Fasting test

Examination revealed that fasting blood sugar and blood sugar during attacks were greater than 2.8mmol/L, in order to further clarify the diagnosis and cause. Patients should undergo a 48 to 72-hour fasting test under close observation, and initially measure blood sugar, insulin, and C-peptide every 6 hours. Generally, about 85% of insulinomas will have hypoglycemia after fasting for 24 hours. After fasting for 48 hours, 95% will have hypoglycemia, and the other 5% will need to fast for 72 hours. If the blood sugar is less than or equal to 3.3mmol/L, the blood sample should be changed to once every hour. If there are symptoms of hypoglycemia or the blood sugar is less than 3mmol/L, the experiment can be terminated. After the fasting is over, blood samples are taken again to measure blood sugar, insulin, C-peptide, and β-hydroxybutyric acid concentrations, and then one milligram of glucagon is injected intravenously, and blood sugar is measured every ten minutes for a total of three times. In case of insulin-mediated hypoglycemia, the plasma β-hydroxybutyric acid concentration should be less than 2.7 mmol/L. If the hypoglycemia is not mediated by insulin, the formation of ketone bodies will increase and the β-hydroxybutyric acid concentration will increase. During the starvation experiment, patients should be active and can drink beverages that do not contain sugar and calories.

Imaging examinations

Abdominal CT, MRI, and ultrasonography can detect most insulinomas. The choice of test depends on the availability of the test and local imaging technology. Transabdominal ultrasonography is often the preferred initial test. Negative imaging does not exclude an insulinoma. If initial imaging does not reveal an insulinoma, additional testing, such as endoscopic ultrasound or selective arterial calcium stimulation testing, is indicated. Isotope-labeled somatostatin receptor imaging may be helpful in localizing the diagnosis.

diagnosis

Diagnostic principles

Diabetes-related hypoglycemia can generally be diagnosed in diabetic patients by carefully questioning their diabetes history and hypoglycemic medication use. Hypoglycemia in non-diabetic patients can be confirmed based on the classic manifestations of hypoglycemia (Whipple’s triad): hypoglycemia symptoms; blood glucose levels below 2.8 mmol/L during an episode; and rapid resolution of hypoglycemia symptoms after glucose administration. For a small number of patients whose fasting blood glucose levels do not decrease significantly or who are not experiencing an episode, multiple fasting or post-absorptive hypoglycemia tests should be performed, and a 48- to 72-hour fasting test may be performed if necessary.

Differential diagnosis

Type 1 and 2 diabetes

It often occurs in obese people and those with a family history of type 2 diabetes. Its symptoms are similar to those of hypoglycemia, but the blood sugar test value is not necessarily low, and elevated insulin may be found.

2. Anemia

This condition often occurs in women of childbearing age and the elderly. Symptoms are similar to those of hypoglycemia, including dizziness, palpitations, and weakness, but the pallor is more pronounced and persistent. Some patients also have a history of heavy menstruation or dark stools, and blood tests may reveal a low hemoglobin level. Symptoms can improve with correction of anemia.

3. Hyperthyroidism

There may be symptoms similar to hypoglycemia, such as sweating, palpitations, and hand tremors, which can be identified through thyroid function tests.

treat

Treatment principles

Treatment of hypoglycemia should aim to relieve the symptoms of insufficient glucose supply to the nerves and correct any underlying causes of hypoglycemia. When hypoglycemia occurs, sugar supplementation should be administered immediately, either orally or intravenously. Once the cause of hypoglycemia is identified, targeted medication, surgery, or other treatment options should be implemented. If medication is the cause of hypoglycemia, the medication should be discontinued immediately and the dosage adjusted.

Acute treatment

If the patient’s condition is mild or they are conscious, they can immediately consume candy, sugary drinks, or sugary beverages. If symptoms do not improve after 15 minutes, they can repeat the candy. If symptoms persist, they can be taken to the emergency room immediately for intravenous glucose.

2. Patients with severe symptoms or unconsciousness should be given intravenous glucose solution immediately.

3. If the blood sugar level does not rise significantly or the patient remains unconscious within a few minutes, the injection should be repeated until the patient is able to eat starchy foods. Glucagon can be injected subcutaneously or intramuscularly if necessary, but it should not be used in patients with hepatic hypoglycemia or alcoholic hypoglycemia.

If blood sugar returns to normal but consciousness persists, intensive care and comprehensive emergency care are necessary as for acute encephalopathy. In addition to measures such as cooling the head and protecting the brain, 20% mannitol should be infused intravenously and dexamethasone should be administered intravenously to actively prevent and treat various complications and comorbidities. Glucocorticoids are indicated for the treatment of refractory hypoglycemia and autoimmune hypoglycemia. After blood sugar stabilizes, the dose should be gradually reduced and discontinued. For patients with chronic adrenal insufficiency, the dose should be gradually reduced to the maintenance dose.

5. Do not feed the unconscious patient to avoid respiratory suffocation.

General treatment

When hypoglycemia occurs, you can take glucose tablets, sugary juice, soft drinks, milk, candy, other snacks or meals orally to relieve symptoms. Clinical symptoms generally resolve within 15 to 20 minutes.

Drug treatment

1. Glucose

The most rapid and effective treatment is oral glucose solution or sugary foods for mild cases. Severe cases, especially those with altered mental status, require an intravenous bolus of 50% glucose, repeated as necessary. Continued intravenous drip of 5% to 10% glucose solution and prompt food intake are necessary to maintain normal blood sugar levels. For mild cases of hypoglycemia in diabetic patients, carbohydrate-containing foods are sufficient. Patients taking glucosidase inhibitors should consume monosaccharides to correct hypoglycemia.

2. Glucagon

Used to raise blood sugar during emergency treatment for hypoglycemic coma. Hyperglycemia may occur, so blood sugar should be monitored during use.

3. Glucocorticoids

Patients whose hypoglycemia is corrected after glucose supplementation or combined glucagon treatment but whose unconsciousness does not improve may be appropriately treated with glucocorticoids.

4. Antiepileptic drugs

Patients with epilepsy should choose epilepsy medication, such as phenytoin sodium. Adverse reactions include dizziness and ataxia.

5. Somatostatin

It can inhibit the growth of insulinoma and treat insulinoma.

Related drugs

Glucose, glucagon, glucocorticoids, phenytoin, somatostatin

Surgical treatment

Surgical treatment may be chosen depending on the cause of hypoglycemia.

Treatment cycle

The treatment cycle for hypoglycemia is generally 1-3 days, but there may be individual differences due to factors such as the severity of the disease, treatment plan, timing of treatment, and personal constitution.

Treatment costs

The cost of treating hypoglycemia can vary significantly from person to person, and the specific cost is related to the selected hospital, treatment plan, medical insurance policy, etc.

Prognosis

General prognosis

The prognosis for patients with hypoglycemia is closely related to the cause and timely treatment. Early diagnosis and prompt treatment of hypoglycemia generally result in a good prognosis. Prolonged coma due to hypoglycemia may cause brain damage and generally results in a poor prognosis. Diabetes-related hypoglycemia generally has a good prognosis, while hypoglycemia caused by serious illnesses such as malignant tumors is less effective with treatment.

Hazards

1. Repeated episodes of severe hypoglycemia, if the best time for treatment is delayed, may cause brain damage and peripheral neuropathy, and in severe cases may cause disability or even death.

2. A small number of patients with hypoglycemia are at risk of passing the disease on to the next generation.

3. A drop in blood sugar will cause symptoms of sympathetic nerve excitement, causing vasoconstriction, inducing angina pectoris, myocardial infarction, and even sudden death.

Self-healing

Some patients can recover on their own if they replenish sugar in time.

Curative

Timely administration of sugar and other treatments for this disease can effectively relieve symptoms.

daily

Overview

Patients with hypoglycemia should pay attention to proper sugar supplementation, regular diet, and gradually increase their exercise in daily life. They should also learn to self-monitor their blood sugar and have some knowledge related to the disease so that they can understand the progress of the disease in a timely manner and seek medical treatment in time.

Psychological care

1. Psychological characteristics

Patients with hypoglycemia may experience symptoms such as palpitations, anxiety, and abnormal mental and behavioral states. They may also experience fatigue and sweating, which may cause them to feel fear and uneasiness.

2. Nursing points

(1) Family members should give patients love and care, communicate with patients, and help patients reduce anxiety and other psychological problems.

(2) Patients should maintain a good attitude, keep their emotions stable, and avoid adverse stimulation; they can relax themselves by listening to music, reading, taking a walk, etc. to reduce their psychological burden; they can consult a doctor to learn more about the disease, eliminate their inner fear, actively cooperate with treatment, and build confidence in overcoming the disease.

Medication care

1. Pay attention to the occurrence of adverse reactions when using drugs. If serious adverse reactions occur, stop using the drug and consult a doctor before using it again.

2. Strictly follow the doctor’s instructions when using medications. Do not stop taking medications or increase or decrease the dosage without permission. Correctly record the type, method, time, dosage, etc. of medications used to avoid adverse effects.

Life Management

1. Live a regular life, ensure adequate sleep and avoid fatigue.

2. Do appropriate physical exercise, do not exercise on an empty stomach, increase the amount of exercise gradually and persistently, stop exercising immediately and eat when hypoglycemia occurs, and carry sugar cubes with you.

3. Pay attention to personal hygiene to prevent infection. For patients with diabetes, dehydration and decreased resistance often lead to dry and itchy skin, which is also prone to skin infections. Regular body scrubbing or bathing should be used to keep the skin clean. Avoid wearing tight socks or hard shoes.

Disease monitoring

People with hypoglycemia should pay attention to their own blood sugar monitoring. The specific methods are as follows:

1. Before blood collection

Wash your hands with mild soap and rinse thoroughly with warm water. Hold your arms down for 30 seconds to help the blood flow to your fingertips.

2. When drawing blood

Ideally, use the ring, middle, and pinky fingers on both sides. After firmly placing the needle against your fingertips, press the lancing device to draw blood (if the amount of blood is insufficient, gently push the other side of your finger; do not squeeze it hard). Then, fully insert the test strip into the bottom of the blood glucose meter, taking care not to insert the test strip in the wrong direction. Ensure that the blood drop on your fingertips comes into contact with the test reaction area of the test strip, ensuring that the amount of blood is sufficient.

diet

Dietary adjustment

Patients with hypoglycemia should maintain a healthy weight on a balanced diet. A low-carbohydrate, high-protein, high-fat diet is recommended. In addition to three main meals per day, 3 to 5 snacks are also recommended.

Dietary recommendations

1. Consume animal foods containing sufficient protein and fat, such as livestock and poultry meat, fish, eggs and soy products.

2. Eat small, frequent meals. It’s best for people with hypoglycemia to eat small, frequent meals, about 6 to 8 times a day. Eating a small snack or dessert before bed can also help.

3. Eat a balanced diet, which should include carbohydrates, vegetables, brown rice, avocado, konjac, nuts, cereals, lean meat, fish, yogurt, and raw cheese.

4. A high-fiber diet helps stabilize blood sugar levels. When blood sugar levels drop, combine fiber with protein foods (for example, bran pancakes with raw cheese or almond jam). Eat fresh apples instead of applesauce; the fiber in apples can suppress blood sugar fluctuations.

Dietary taboos

1. Strictly limit the consumption of refined sugars such as monosaccharides and disaccharides, such as glucose, fructose, granulated sugar, brown sugar, and sucrose-based pastries, beverages, and canned sweets.

2. Daily dairy consumption should not exceed 500g.

3. Try to eat less refined and processed products, such as instant rice, potatoes, white flour, etc.

4. Avoid drinking alcohol and quit smoking.

prevention

Preventive measures

Hypoglycemia is a preventable disease. Specific preventive measures include the following:

1. Eat on time and maintain a regular lifestyle. Do not delay meals. If you must delay a meal, eat some cookies, fruit, or chocolate beforehand.

2. Diabetic patients should follow the doctor’s advice and take medication correctly to avoid hypoglycemia.

3. Keep the amount of exercise constant and avoid strenuous exercise such as running on an empty stomach.

4. Actively treat diseases that may cause hypoglycemia, such as malnutrition, heart failure, etc.

5. Women who deliver vaginally can eat small, frequent, easily digestible meals during labor. Women who deliver by cesarean section can receive intravenous glucose supplements. If possible, breastfeed the newborn within 30 minutes of delivery. Pay special attention to the blood sugar levels of premature and low-birth-weight infants, who are at high risk for hypoglycemia. Those who cannot be fed enterally can receive 10% glucose intravenously to prevent neonatal hypoglycemia.

Medical Guide

Home treatment

If the patient has symptoms of hypoglycemia, such as paleness, trembling hands, sweating, and palpitations, family members can provide the following help:

1. If the patient is conscious, immediately give them carbohydrates that can quickly increase their blood sugar, such as a bottle of juice or a cup of sugar water (100-150 ml, about 15 grams of sugar). Wait 15 minutes and observe whether the symptoms improve.

2. If the patient still has symptoms of hypoglycemia, allow him to drink sugar water or juice;

3. If you have a blood glucose meter, you can check your blood glucose level yourself.

Emergency (120) indications

1. Sudden convulsions, loss of consciousness or coma;

2. Other emergency situations occur.

All of the above require emergency treatment, and call 120 emergency number if necessary.

Outpatient indications

1. Recurrent palpitations, anxiety, and hand tremors;

2. Accompanied by cognitive impairment and psychomotor abnormalities;

3. Diabetic patients test their blood sugar at home and find that their blood sugar is less than 4mmol/L;

4. Other severe, persistent or progressive symptoms and signs occur.

All of the above require timely medical treatment.

Treatment department

1. If the condition is critical or the symptoms are severe, please go to the emergency department immediately.

2. For patients with stable conditions, the first department to visit is usually the endocrinology department.

Medical preparation

1. Make an appointment in advance and bring your ID card, medical insurance card, medical card, etc.

2. On the day of the appointment, you can wear loose clothes to facilitate the physical examination.

3. If you have had medical treatment recently, please bring relevant medical records, examination reports, laboratory test results, etc.

4. If you have taken some medicine to relieve symptoms recently, you can bring the medicine box with you.

5. Family members can be arranged to accompany the patient to seek medical treatment.

6. Prepare a list of questions you want to ask in advance.

Questions your doctor may ask

1. What symptoms do you have? How long have they been present?

2. Have your symptoms gotten worse or better since the onset of your illness? What causes the onset, worsening, or relief of your symptoms?

3. Do you have a history of diabetes? What diabetes medications do you take?

4. Have you ever monitored your blood sugar at home? What is your blood sugar level like on a regular basis?

5. Do your symptoms improve after taking sugar supplements?

6. What are your eating habits like? Do you usually drink a lot of alcohol?

7. Do you have any other diseases?

8. Do any relatives have similar symptoms or diseases?

9. Have you ever received treatment? What was the treatment process like? What was the treatment effect?

What questions can patients ask?

1. What is the most likely cause of my hypoglycemia?

2. Is the situation serious now?

3. What tests do I need to do?

4. What treatments are available? Which one do you recommend?

5. What should I pay attention to while taking the medicine?

6. Are these covered by medical insurance?

7. Do you have other diseases? Will this affect the treatment effect?

8. How can I prevent hypoglycemia? What should I pay attention to in my daily life?

9. Do I need to monitor my blood sugar? How often?

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