pink panther - diabetes management - chapter 6

TOPIC:Prevention,Detection, andTreatment ofAcuteComplications(hypoglycemia low blood sugar)TEACHING OBJECTIVES:1. Present the symptoms, causes,

and treatment of mild,moderate and severehypoglycemia.

2. Identify the appropriate time tocontact the healthcare provider.

LEARNING OBJECTIVES:1. Define mild, moderate and

severe low sugar symptoms,causes and treatment.

2. State the appropriate time tocontact a healthcare provider.

Chapter 6

Low Blood Sugar(Hypoglycemia orInsulin Reaction)

H. Peter Chase, MDCarolyn Banion, RN, MSN, CPNP, CDE

There are two emergency problems in blood sugar controlfor people with diabetes. The first, discussed in this chapter, islow blood sugar or hypoglycemia. (The second, discussed inChapter 15, is high blood sugar or ketoacidosis.) Low bloodsugar comes on quickly and must be treated by the person,family or friends. Early treatment helps prevent a more severereaction and possible hospitalization.

Any time a person has received a shot of insulin, or an oraldiabetes medicine, there is a chance of a low blood sugarreaction. The family of a person with newly diagnosed diabetesmust know the signs and symptoms of hypoglycemia beforegoing home the first night.

A normal random (non-diabetic) blood sugar is usuallybetween 70-140 mg/dl (3.9-7.8 mmol/L). Normal fastingvalues are usually between 70 and 100 mg/dl (3.9-5.5mmol/L). For purposes of this book, we define a true lowblood sugar as < 60 mg/dl (< 3.2 mmol/L). The AmercianDiabetes Association (ADA) defines a low blood sugar level asany level < 70 mg/dl (< 3.9 mmol/L).

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36 Chapter 6 Hypoglycemia (Low Blood Sugar)

CAUSES OF LOW BLOODSUGAR

Hypoglycemia (low blood sugar) occursbecause the body doesnt have enough sugar toburn for energy. The level of sugar in the bloodfalls too low. Sometimes it is called an insulinreaction, a reaction or a low.

Frequent causes are listed below:

Meals and snacks that are late or missed

Extra exercise that burns more sugar thanusual

An insulin or oral medicine dose that is toohigh

An insulin dose peaking at a different timethan usual

Giving a shot into muscle which results inrapid absorption of insulin

Making a mistake in the drawing up andgiving of an insulin dose

Taking a bath or shower (or hot tub) soonafter taking a shot of insulin. (The bloodvessels in the skin dilate from the hot waterand cause insulin to be rapidly absorbed.) Itis always wise to wait at least 90 minutes totake a shower, bath or hot tub after aninsulin shot. It is only necessary to wait ashort time (10-15 minutes) after being inhot water to then do the shot.

Prevention of low blood sugars (lows) ismuch wiser than having to treat the lows.When too many lows occur, the stored sugarand adrenaline (epinephrine) are drained.When this occurs, the usual symptoms of a lowmay not occur. In addition, over treatment(eating too much) after a low can cause a highblood sugar and can increase the HbA1c value(Chapter 14). Paying attention to the sevencauses of lows listed above will help to decreasethe number of low blood sugars.

SYMPTOMS OF LOW BLOODSUGAR

Usually the body gives a warning when lowblood sugar or an insulin reaction is developing.DIFFERENT PEOPLE GET DIFFERENTWARNINGS.

These signs are the most common warningsof an insulin reaction:

Hunger: the person may either feel hungryor have an upset stomach (nausea)

Shakiness: the persons hands or body mayfeel shaky

Sweatiness: the person may sweat morethan usual (often a cold sweat)

Color: the face may become pale, gray or red

Headache

Confusion: the person may feel or lookspacey or may appear dazed

With an insulinreaction, you mayexperience confusionor drowsiness.

Chapter 6 Hypoglycemia (Low Blood Sugar) 37

Drowsiness: the person may yawn, feelsleepy or may have trouble thinking clearly;preschoolers frequently get sleepy

Behavioral changes: changes in behaviorare quite common; often the person maycry, act intoxicated, or they act angry, orthey may feel weak or anxious

Double vision: the person may see doubleor the pupils of the eyes may get bigger; theeyes may appear glassy; the whites of theeyes may look blood shot

Loss of consciousness

Seizure or convulsion: both loss ofconsciousness and convulsion occur late inthe reaction. They are usually the result ofnot treating a reaction quickly enough.

The first four initial symptoms (hunger,shakiness, sweatiness and color) are due to theoutput of the fight or flight hormone,adrenaline (epinephrine is another name).Later symptoms are more related to the lack ofsugar to the brain. Sugar is the main source offuel for the brain. If the low sugar continuestoo long, the brain can be harmed. It isparticularly important to prevent severe lowblood sugar in young children. The braingrows very rapidly in the first four years of life.

NIGHTTIME LOWSPeople may wake up with symptoms (infants

may just cry) when lows occur during the night.The symptoms may be the same as during thedaytime although there are sometimes special clues:

Inability to sleep or waking up alert,hungry, restless, moaning, etc.

Waking up sweating

Waking up with a fast heart rate

Waking up with a headache

Sleep walking

Waking up feeling foggy-headed or withmemory loss

Low blood sugar, then an unusually highblood sugar or positive urine ketones(possible rebounding)

IF ANY OF THESE DO OCCUR,TEST YOUR BLOOD SUGARIMMEDIATELY. If low, treat appropriatelyand call the doctor or nurse the next day. Alsothink about what was different the previous day(extra exercise, extra insulin, less food, etc.).This will allow planning ahead to prevent a lowwith a similar cause in the future. Preventingminor lows during the night is very important.More than half of severe lows occur duringthe night. One study in children found that 75percent of severe lows occur during the night.The use of Lantus insulin (Chapter 8) andinsulin pumps rather than insulins that peakduring the night (e.g., NPH at dinner orbedtime), is now helping to reduce thenighttime lows.

RECOGNIZING A LOWBLOOD SUGAR

It is important to recognize a low bloodsugar at the earliest possible time. By doing this,the reaction will not progress to a severereaction. The common symptoms are listedabove, but they can vary from person to person.The early warning signs of a reaction are due tothe release of a hormone called adrenaline.Most people make it when they are excited orscared. Another name for this fight or flighthormone is epinephrine. It causes shakiness,sweating, dilated pupils, a rapid heart rate andother symptoms. During the day, it is releasedwhen the blood sugar falls below 70 mg/dl (3.9mmol/L). People who have had diabetes for alonger period of time often make less of theprotective hormones with low blood sugar,particularly at night. Some people tend to haveonly mild reactions and can easily detectsymptoms. This seems to be more common inthe first few years after diagnosis. Others mayhave more difficulty detecting symptoms. Thisseems to happen to people who have haddiabetes longer or whose blood sugars run atmore normal levels. A term, hypoglycemic


unawareness is sometimes applied to thiscondition, and it is discussed later in thischapter. Sometimes this is due to less adrenalinebeing available. In other cases, the lack ofsymptoms may be due to a slow or less dramaticfall in blood sugar levels, such as from 70 to 50mg/dl (3.9 to 2.7 mmol/L) rather than from170 to 50 mg/dl (9.5 to 2.7 mmol/L). Somepeople are less likely to detect low blood sugarin the morning because the sugar has fallengradually during the night. Thus, adrenalinerelease and its symptoms did not occur.Symptoms are more likely to occur with agreater and faster fall of a blood sugar level.

Different children learn to tell if they havelow blood sugar at different ages (see Chapter18). It may be possible to train young children(or older people who have difficulty detectinglow blood sugars) to recognize certain signs.

Parents may frequently need to remind ayoung child

Remember how you felt shaky (orwhatever the feeling was [one toddlerwould say, Theres a tiger in mytummy.]) and you came and told me?You did a good job! Remember to tell agrown up if you feel that way again.

Ask the child how they feel when a low isfound. This will reinforce their awareness ofthe symptoms. For very young children, theparent can often tell when the child has lowblood sugar by the type of cry or fussinesshe/she presents. Young children may beunaware of lows because they are busy playing.It is critical for adults to be aware of the needfor snacks. A snack is especially important whena child discontinues naps during the day. It canbe compared with an adult adding a newexercise program.

PREVENTING INSULINREACTIONS (THINKINGAHEAD)

It is important to prevent lows. This mayallow the stores of epinephrine and glucagon

(and other protective hormones) to build upso they are available when needed.

Considerations in preventing insulinreactions:

Snacks can be important when:

4 heavy physical exercise or all day exercise isplanned: hiking, skiing, etc.

4 the bedtime blood sugar is below 130mg/dl (7.3 mmol/L).

4 a person has a low (but be careful not to eatin excess).

Insulin:

4 Reduce the dose of insulin which will beacting during the exercise period.

4 Take the insulin injection AFTER a hotshower, bath or hot tub.

4 For some people, with careful insulin doseadjustments, or using Lantus insulin or aninsulin pump, extra snacks may not beneeded (unless < 130 mg/dl [< 7.3mmol/L] at bedtime).

4 If doing corrections for high blood sugars atbedtime or during the night, use half theusual dose.

Blood sugar:

4 Doing extra blood tests before, during andafter periods of exercise will help to preventlows and plan for future activity.

4 Knowing a blood sugar level can help decidethe amount of treatment needed.

4 Do a blood sugar test during the night if itwas a heavy exercise day.

4 Always do a recheck if the value was lowprior to the bedtime snack (to be certain itcame back up).

False Reaction (False-Low)

A rapid fall in blood sugar can also causean adrenaline release and symptoms even if alow blood sugar does NOT occur. We call thisa false reaction. The symptoms of low blood


sugar occur, but the blood sugar is not low. Acommon example is when children eat lunch atschool. Their blood sugar rises to a value ofperhaps 250 mg/dl (13.9 mmol/L) aftereating. They then go outside to play and thesugar might fall to 150 mg/dl (8.3 mmol/L)fairly rapidly. Adrenaline is released and thesymptoms of having a reaction occur. Yet theirblood sugar is 150 mg/dl (8.3 mmol/L) andthey DO NOT HAVE LOW BLOODSUGAR. It was just the rapid fall in bloodsugar that caused an adrenaline release andmade them feel like they were having areaction. Since the sugar is not truly low, theydo NOT need to drink sugar pop (soda) orjuice, which will only raise their blood sugar.They might feel better if they ate some solidfood, such as crackers or fresh fruit. It isimportant to remember that THE ONLYWAY TO TELL IF SOMEONE HAD ARAPID FALL IN BLOOD SUGAR OR ATRULY LOW BLOOD SUGAR IS BYDOING A BLOOD SUGAR TEST.Whenever possible, a blood sugar test shouldbe done when the symptoms of low bloodsugar occur.

TREATMENT FOR A LOW BLOOD SUGAR(INSULIN REACTION see Tables 1 and 2)

The general rule is to GIVE SUGAR INSOME FORM AS FAST AS POSSIBLE. If thereaction is not severe, do a blood sugar testfirst. If you are not able to do a blood sugar,then just give milk, juice or sugar pop. Aperson with diabetes wont get sick from excesssugar. It will just cause high blood sugar andthen be passed in the urine. Insulin reactionscome quickly and should be treated at once bythe person, parent, friend or teacher.

Different forms of sugar can be carried withthem to treat low blood sugar. PEOPLEWITH DIABETES SHOULD CARRYSUGAR PACKETS OR GLUCOSE TABLETSIN THEIR POCKETS AT ALL TIMES FOR

EMERGENCIES. Candy is too tempting. Italso may be taken by other children. A specialpocket for sugar packets can be sewn inside ofgym shorts. Some people carry them in ajogger wallet attached to a shoe. Others slippackets in high stockings. It is often best towrap the packet in foil or a plastic bag in case ofleaks. Insta-Glucose comes in a tube andlooks like toothpaste. It is available in mostpharmacies. A tube of clear cake gel or honeytube from the grocery store will also work.After the blood sugar is back up, the personmay want to eat some other longer-lasting solidfood, like crackers or 1/2 a sandwich. Theliquid sugar will be absorbed more quickly if theperson waits before eating the solid food.Gradually, each person will become familiarwith the type of reactions that occur. Theperson will learn how severe the reactions tendto be, when they are most likely to occur andhow best to treat them.

Eventually, as a person becomes morefamiliar with diabetes, it may be possible totreat the various reactions differently.Remember, when possible, it is always wise todo a blood sugar if the reaction is not severe. Ifthe level is above 60 mg/dl (3.3 mmol/L), itmay be possible to treat the reaction with freshfruit and solid food rather than milk, juice orsugar pop. ALSO, REMEMBER THAT ITTAKES 10 TO 20 MINUTES FOR THEBLOOD SUGAR LEVEL TO RISE, ANDIT IS WISE TO WAIT UNTIL THEVALUE IS BACK UP TO RETURN TONORMAL ACTIVITY. IT ISIMPORTANT TO TEST THE BLOODSUGAR AFTER THE LOW BLOODSUGAR TO MAKE SURE IT HASRETURNED TO NORMAL. SOMEPEOPLE USE THE RULE OF 15,TAKE 15g OF CARBOHYDRATE ANDTEST AGAIN IN 15 MINUTES. (THENIF THE BLOOD SUGAR IS STILLBELOW 70 mg/dl [3.9 mmol/L], HAVEANOTHER 15g OF CARBOHYDRATE.)Some sources of quick-acting sugar withappropriate amounts for people of differentages are given in Table 1.


Table 1Sources of Quick-Acting Sugar (Glucose) for HypoglycemiaFOOD AGE(Measured in grams 5 years or less 6-10 years over 10 yearsof carbohydrae) (10g) (10-15g) (15-20g)

Glucose Tabs (4g each - check label;some = 5g) 2 3-4 4-5

Instant Glucose(1 tube = 31g) 1/3 tube 1/3-1/2 tube 1/2-2/3 tube

Cake gel(1 small tube = 12g) 1 tube 1 tube 1-2 tubes

Apple juice(1/2 cup = 15g) 1/3 cup 1/3-1/2 cup 1/2-2/3 cup

Orange juice(1/2 cup = 15g) 1/4-1/2 cup 1/2-3/4 cup 3/4-1 cup

Sugar(1 tsp = 4g) 2 tsp 3-4 tsp 4-5 tsp

Honey (1 tsp = 5g;do not use if child isless than two years old) 2 tsp 2-3 tsp 3-4 tsp

Regular pop (soda)(1 oz = 3g) 3 oz 4-5 oz 5-6 oz

Milk(12g/cup) 3/4 cup 1 cup 1 1/2 cup

LIFE-SAVERS

(2.5g each) 4 4-6 6-8

Skittles

(1g each) 10 pieces 10-15 pieces 15-20 pieces

Sweet Tarts

(1.7g each) 6 pieces 6-8 pieces 8-12 pieces

Raisins(1 Tbsp = 7 1/2g) 1-2 Tbsp 2 Tbsp 2 1/2 Tbsp

g = gram; tsp = teaspoon; Tbsp = Tablespoon


TREATMENT BY SEVERITY OF REACTION(see summary, Table 2):

Mild Reaction (such as hunger at anunusual time, pale face, shakiness orirritability): If possible, do a blood sugartest. If below 60 mg/dl (3.3 mmol/L),give a glass of milk, a small glass (4 oz) ofjuice or sugar pop (soda). Wait 10-15minutes for absorption of the liquid sugarand then give solid food (crackers,sandwich, fresh fruit, etc.). If the bloodsugar is above 60 mg/dl (3.3 mmol/L),give just solid food.

Moderate Reaction (very confused orspacey, very pale or very shaky): Give Insta-Glucose, Reactose, Monojel or anysource of simple sugar, such as sugar pop orjuice. One-half tube of the Insta-Glucosecan be placed between the cheeks and gums,and the person should be told to swallow.Do a blood sugar test as soon as it ispossible. Always check for the risk ofchoking. Repeat the blood test after 10-15minutes to make sure it is above 60 mg/dl(3.3 mmol/L). If not, repeat the initialtreatment and wait another 10-15 minutes.Once the blood sugar has risen above 60mg/dl (3.3 mmol/L) give solid food.

Severe Reaction: If the person iscompletely unconscious, it is risky to put theconcentrated sugar around the gums. Itcould get into the airway. It is better to justgive glucagon as instructed in Table 3 in thischapter. Remember to do the blood sugarlevel as soon as possible. If the person doesnot improve after 10-20 minutes, it may benecessary to call 911 to get extra help. Asecond dose (same amount) of glucagon(from the same vial) can also be given. Inthe preliminary part of the Diabetes Controland Complications Trial (DCCT; Chapter14), one of every 10 people (10 percent)receiving standard treatment had a severereaction each year. One of four people (25percent) on intensive treatment (including

insulin pumps) had a severe insulin reactioneach year. Every family must have glucagonavailable and know how to use it (see Table3). Our current hypoglycemia video may behelpful in understanding how to useglucagon. Adjustments in the next insulindose may be necessary. Call your diabetescare provider if you need help making thisadjustment.

We are concerned about any blood sugarbelow 60 mg/dl (3.3 mmol/L). Whenthese are obtained frequently in routinetesting, the insulin dose or snacks should bechanged so that further low values do notoccur. In a child under five years old, we areconcerned about values below 70 mg/dl (3.9 mmol/L). When values are below theselevels at the time of an insulin injection, weusually recommend not giving the usualamount of Humalog or NovoLog insulin (atleast until after eating). If two or three valuesbelow 60 mg/dl (3.3 mmol/L) are presentat the same time of day in the same week, adecrease in insulin dose is probably needed.CALL THE DIABETES CAREPROVIDER IF HELP IS NEEDED.

Hypoglycemic Unawareness: Sometimeslow blood sugars will be found duringroutine testing, and the person will not havehad symptoms. This may be due to a verygradual fall in the blood sugar, or in youngchildren, because they have not learned torecognize the symptoms. Some adults withvery strict sugar control do not releaseadrenaline and may have the problemmedically referred to asHYPOGLYCEMIC UNAWARENESS.In this case, they must not aim for suchstrict blood sugar control. Sometimes theinsulin dose can be lowered. After bloodsugars have been higher for two or threeweeks, it may be possible to again recognizelow blood sugars.

One-sided Weakness (paralysis): It is notknown why, but on rare occasions somepeople experience weakness (or paralysis) onone side of the body with a severe insulin


Table 2Hypoglycemia: Treatment of Low Blood Sugar (B.S.)

Always check blood sugar level!Low Blood SugarCategory MILD MODERATE SEVERE

Alertness ALERT NOT ALERTUnable to drinksafely (choking risk)Needs help fromanother person

UNRESPONSIVELoss of consciousnessSeizureNeeds constant adult help (positionof safety)Give nothing by mouth (extremechoking risk)

Symptoms Mood ChangesShaky, SweatyHungryFatigue, WeakPale

Lack of FocusHeadacheConfusedDisorientedOut of Control(bite, kick)Cant Self-treat

Loss of ConsciousnessSeizure

Actions to take 4 Check B.S.4 Give 2-8 oz

sugary fluid(amount agedependent)

4 Recheck B.S. in10-15 min.

4 B.S. < 70,repeat sugaryfluid andrecheck in 10-20 min.

4 B.S. > 70, (givea solid snack)

4 Place in position ofsafety

4 Check B.S.4 If on insulin pump,

may disconnect orsuspend until fullyrecovered from lowblood sugar (awakeand alert)

4 Give Insta-Glucoseor cake decoratinggel - put betweengums and cheek andrub in.

4 Look for person towake up

4 Recheck B.S. in 10-20 min.

4 Once alert followactions underMild column

(Can use low doseglucagon: [1 unit peryear of age], if verydisoriented or out ofcontrol)

4 Place in position of safety4 Check B.S.4 If on insulin pump, disconnect or

suspend until fully recovered fromlow blood sugar (awake and alert)

4 Glucagon: can be given with aninsulin syringe like insulinBelow 5 years : 30 units 5-16 years: 50 units Over 16 years: 100 units (all ofdose)

4 If giving 50 or 100 unit doses, mayuse syringe in box & inject throughclothing.

4 Check B.S. every 10-15 min. until> 80

4 If no response, may need tocall 911

4 Check B.S. every hour x 4-5 hours4 High risk for more lows x 24 hours

(need to food intake and insulin doses)

Recovery time 10-20 minutes 20-45 minutes Call RN / MD and report the episode

Effects can last 2-12 hours


reaction. This can last for one to 12 hours,but eventually clears. It is particularlyworrisome to doctors in emergency rooms.They often insist on a very expensiveevaluation to prove that a stroke has notoccurred.

Preventing Severe Lows: A parentsgreatest fear is a severe hypoglycemicreaction. This is often the biggest factor innot achieving good sugar control (a lowHbA1c level, Chapter 14). Unfortunately,the most common time for severe lows tooccur is during the sleeping hours. This isbecause the adrenaline response tohypoglycemia is lower when sleeping andthe person is not awakened when the bloodsugar falls. The good news is that theincidence of nighttime severe lows is nowdecreasing. This is due to:

1. Probably the main reason for thedecrease is the recent use of basal/bolusinsulin therapy using insulin analogs.Most important is the flat Lantus basalinsulin, contrasting with the large peaksof NPH or Lente insulins workingduring the night in past years. Therapid-acting analogs (H, NL, AP) alsoact during the post meal-time rises inblood sugar, rather than after the rise inblood sugar has already occurred (asoccurs with human Regular insulin).This has decreased late-evening lows.The basal insulin from insulin-pumptherapy also avoids the peaks during thenight and helps to prevent lows.

2. The widespread use of home glucosemonitoring has helped to reduce thesevere nighttime lows. It has beenshown that the risk is greater when thepre-bedtime glucose level is below 130mg/dl (7.3 mmol/L). Extra snackswhen the level is low obviously help ifthe value is really low at bedtime. It isimportant to do a repeat check later tomake sure the blood sugar level hascome back up ( 10 percent of bloodsugars dont come back up).

3. Education is also a big factor. Familiescan think-ahead and reduce the insulinacting during the night if there has beenunusual exercise that day. Parents willoften get up at night and do a bloodsugar on those nights.

4. Eventually there will be continuousglucose monitors that read accurately atlow glucose levels and give alarms toalert families. The current monitors (seeChapter 7) give approximately one falsealarm for every true low. This willimprove and will someday allow us toprevent most severe lows. In themeantime, we have to do the best wecan with the measures outlined above.

GLUCAGONGlucagon is a hormone made in the

pancreas, like insulin. However, it has theopposite effect of insulin and raises the bloodsugar level. It is rarely needed, but we askfamilies to keep it on hand. The expiration dateon the box should be checked regularly and, ifoutdated, a new bottle should be obtained. If avery severe reaction occurs and the person losesconsciousness, glucagon should be givenpromptly. It can be stored at room temperature.It should not reach a temperature above 90 orbelow freezing. It can be taken in a cooler withthe insulin and blood sugar strips for trips awayfrom home.

Use of Glucagon

1. Severe Low Blood Sugar

Glucagon comes in a bottle containing 1mg as a tablet or powder. There is a syringecontaining diluting solution in the emergencykit. The method for giving glucagon is shownin Table 3. This table may be copied andattached to the glucagon kit.

Sometimes vomiting will occur after a severereaction. This may be from the persons ownglucagon output or from the glucagon that wasinjected. It usually does not last very long, andif the blood sugar is above 150 mg/dl (8.3


Table 3Glucagon Injections When To and How To

Use when a person is unconscious or having a seizure.

Keep in a convenient and known place. Store in a refrigerator duringhot weather. Protect from freezing.

Keep a 3cc syringe available or use the fluid-filled syringe in theemergency kit. An insulin syringe and needle can also be used(preferably a 1.0cc syringe). Some people tape the syringe to the kit sothey have this readily available (see video on hypoglycemia).

If you have the emergency kit, the fluid does not need to be withdrawnfrom bottle 1 (diagram at right) as it is already in the syringe. Put the liquidinto the glucagon vial and swirl gently to mix. The large syringe that theliquid was in can also be used to give the glucagon injection. Draw up thedose indicated below. Clear the air pointing the needle upward.

Withdraw from the mixed glucagon bottle: If using an insulin syringe, put needle into center of stopper.

(Estimate dose if using the emergency kit syringe.)

0.3cc (30 units) for a child less than six years old0.5cc (50 units) for a child 6-18 years of age1.0cc (100 units) for an adult over 18 years of ageIf using the syringe that comes in the emergency kit, inject into deepmuscle (in front of leg or upper, outer arm) though it is OK to injectinto the subcutaneous fat. Inject through clothing if needed. If theglucagon is drawn into an insulin syringe then give it just as you would an insulin shot. If a blood sugar has not yet been done, it can be done now.

Wait 10 minutes. Check blood sugar. If still unconscious and bloodsugar is still below 60 mg/dl (3.3 mmol/L), inject second dose ofglucagon (same amount as first dose).

If there is no response to the glucagon, or if there is any difficultybreathing, call paramedics (or 911).

As soon as he/she awakens, give sips of juice, sugar pop or sugar in waterinitially. Honey may help to raise the blood sugar for children over theage of 1 year. After 10 minutes, encourage solid food (crackers andpeanut butter or cheese, sandwich, etc.).

Notify diabetes care team of severe reaction prior to next insulininjection (so dose can be changed if needed). Complete recovery maytake 1-6 hours.

Please copy this page as often as you wish. Tape a copy to the box of glucagon.

1. Insert1/2cc ofair intofluidbottle(1ccwont fit).Rotate tomix.

2. Draw out1cc offluid frombottle.

3. Inject the1cc offluid intobottlewithtablet.Mix.


mmol/L), it is not a big problem. If the personis lying down, the head should be turned to theside to avoid choking. Urine or blood ketonesshould be checked (see Chapter 5) as they cansometimes also form. If the family is concernedabout the ketones, if the blood sugar did notrise, or if the vomiting continues, the diabetescare provider should be called.

2. Low Blood Sugar and Vomiting

Sometimes the blood sugar can be low (< 60 mg/dl [< 3.3 mmol/L]) and the personcannot keep any food down. Glucagon can bemixed (Table 3) and given just like insulin using an insulin syringe. The dose is one unitper year of age up to age 15 years. Olderpeople can just use the 15 units.

For example: a five-year-old would get fiveunits or a 10-year-old would get 10 units.

If the blood sugar is not higher in 20-30minutes, the same dose can be repeated. Thistreatment has saved many ER visits.

DELAYED HYPOGLYCEMIADelayed hypoglycemia is also discussed in

Chapter 13 on exercise. It usually occurs from4-12 hours after exercise, however it can occurup to 24 hours after the exercise. For somepeople, blood sugars can be high after exercise.This is due to the normal response of releasingadrenaline during exercise (or from the extrasnacks). Adrenaline causes sugar to come outof the liver and raise the blood sugar. At somepoint after the exercise, the adrenaline levels goback down (sometimes not until the time ofsleep), and the sugar moves back into themuscle and liver. The result can be a low bloodsugar or delayed hypoglycemia.

Prevention involves lowering the insulin dose.This must be done after heavy exercise eventhough the blood sugar may be high. Takingextra carbohydrate at bedtime (even with highblood sugar) may also be helpful. Exercise isessential for the heart and cardiovascular system.Therefore, it is important to always be thinkingabout how to best prevent post-exercise lows.

RECORD ALL INSULINREACTIONS

Record insulin reactions in your recordbook. Many families circle all values < 60mg/dl (< 3.3 mmol/L). Try to identify andrecord the cause of any low or high bloodsugars (Table 4). If more than two mild insulinreactions occur in a short time period, call thediabetes care provider to adjust the amount ofinsulin. It is usually possible to call duringoffice hours, but if a severe reaction occurs, callthe care provider prior to giving the nextregularly scheduled insulin shot.

MEDICAL IDENTIFICATION

In case of a severe insulin reaction,EVERYONE needs to know about the diabetes.This includes teachers, strangers, police, co-workers, friends and medical personnel. Theperson with diabetes should wear a bracelet ornecklace with this information. A card in thewallet is not good enough; this may not befound by paramedics. A diabetes ID card canalso be stapled to the registration of the car inthe glove compartment. Bracelets or necklacescan be found at most pharmacies or medicalsupply houses.

The MedicAlert Foundation (provides MedicAlert tags)

2323 Colorado AvenueTurlock, California 95382

888-633-4298www.medicalert.org

The MedicAlert tag includes a number thatcan be called 24 hours a day for informationconcerning both the person and the doctor. Theminimum charge for the bracelet or necklace andkeeping the information readily available 24hours per day is $35. Then the annualmembership renewal after the first year is $20.

A bracelet, necklace or medallion with yourpersonal medical information (name, conditionand medications) can be engraved and orderedthrough American Medical Identifications, Inc.


The prices for an identification tag start at$21.95.

American Medical Identifications, Inc.P.O. Box 925617

Houston, Texas 77292800-363-5985

www.americanmedical-id.com

Colorful sports bracelets are sometimespreferred and can be ordered from FIFTY 50PHARMACY. The cost per bracelet rangesfrom $9.95 to $14.95 plus $4.50 for shipping.Mail your order with payment to:

FIFTY 501420 Valwood Parkway, Suite 120

Carrollton, Texas 75006Phone: 800-746-7505

www.fifty50.com

Medical charms are also popular. Thesework well for attaching to the toddler shoelaces. The addresses are:

Miss Brookes CompanyP.O. Box 558

Bryant, Arkansas 72089Phone: 888-417-7591www.missbrooke.com

For those who desire additional choices, seewww.tah-handcrafted-jewelry.com.

For people who will not wear a necklace orbracelet, a watch or shoe tag may be the nextbest choice. There are medallions that stick tothe front of a wallet, cell phone, insulin pump,etc. These can be purchased from LIFETAG,Inc., 888-LIFETAG or www.lifetag.com [email protected].

Toddlers should not wear a neck chain (toorisky), but they often do well with anklebracelets, charms or a medallion laced in theshoe. The sports bracelet described aboveworks quite well around the ankle.

Table 4Some Factors That Change the Blood SugarLowers:

Insulin

Hot bath, showers or hot tubs mayincrease insulin absorption and cause alow blood sugar

Exercise, although for some people, thevalues may be higher immediatelyfollowing exercise

Less food or eating late

Raises:Sugar intake

Glucagon

Hormones such as glucagon, adrenaline,growth hormone and cortisol(prednisone); their action is opposite tothat of insulin

Illness (which may cause ketones)

Rapid growth; teenagers usually requiremore insulin with increased growth

Menstrual periods (may cause ketones)

Emotions such as anger and excitement;some younger children can have lowerblood sugars with extra excitement

Inhalers given for asthma which haveepinephrine derivatives in them


DEFINITIONSAdrenaline (used collectively to includeepinephrine and non-epinephrine): Theexcitatory hormone. This is released with a lowblood sugar or a rapid fall in blood sugar, whichthen causes the symptoms of low blood sugar(shaking, sweating and pounding heart).

Glucagon: A hormone also made in thepancreas (like insulin) that causes the bloodsugar to rise. It is available to inject into peoplewhen they have severe (unconscious) insulinreactions.

Hypoglycemia: The term used for a low bloodsugar (insulin reaction).

Hypoglycemic unawareness: The term usedto describe low blood sugars without the personhaving any warning signs or symptoms.

Insta-Glucose, Monojel, or Reactose: Sourceof concentrated sugar that can be purchased. Itcan be given to a person in case of low bloodsugar.

Ketoacidosis (Acidosis): What happens in thebody when not enough insulin is available.Blood sugar is usually high at this time.Moderate or large ketones (acetone) are presentin the urine. See Chapter 15.

Rebounding (Somogyi reaction orbouncing): The process of blood sugars fallingto low levels and then rebounding to highlevels. Ketones may sometimes be presentwhen this occurs.

Seizure (convulsion): Loss of consciousnesswith jerking of muscles. This can occur with avery severe low blood sugar (insulin reaction).

QUESTIONS AND ANSWERSFROM NEWSNOTES

Do we still need to keep glucagon?

YES.

The current statistic (from threestudies) is that four percent to 13 percent ofstandard insulin-treated patients have one ormore severe episodes of hypoglycemia eachyear. With intensive insulin therapy in theDCCT, 25 percent (one in four) of subjects hada severe reaction each year. Glucagon shouldbe given anytime there is loss of consciousnesswithout being able to arouse the person. Ifparamedics are to be called, it is still wise to givethe glucagon before they arrive.

The biggest change in giving glucagon is thattwo studies have shown it will work just as fastwhen given subcutaneously (the same place asinsulin) as when given into muscle. People usedto think it always had to be given into muscle.

The Eli Lilly Company GlucagonEmergency Kit comes with the diluting solutionalready in the syringe ready to be injected intothe bottle with the powdered glucagon formixing. The syringe and needle they providecan then also be used for the subcutaneous orintra-muscular injection (either is fine).

Some people have rebounding, a high bloodsugar and even ketones after glucagon.Vomiting can also occur, but these side effectscan be handled.

Since I have changed to threeinjections of insulin per day, and myHemoglobin A1c has come down, I

dont seem to feel low blood sugar reactions.Is this common?

Unfortunately, this is not unusual. Itis called hypoglycemic unawareness.People on intensive insulin therapy

often do not make the counter-regulatory

QA

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hormones as effectively as they did previously.Adrenaline (epinephrine) output is sometimesreduced in people with very tight sugar control.This is probably the most important hormone,which normally increases with low blood sugarand then causes the symptoms (shakiness,sweatiness, rapid heart beat, etc.). Sometimes itis possible to reduce the insulin dose to let theblood sugars run a bit higher for two or threeweeks in order to regain the ability to feel lowblood sugars.

Other hormones which normally help toraise the blood sugar may also have reducedoutput following intensive insulintherapy. Production of thehormone glucagon, made in thepancreas like insulin (normally), isreduced in most people who havehad diabetes for longer than oneyear. Therefore, it also may not beavailable to help raise the bloodsugar. It is important to let yourdiabetes care provider know if youare having low blood sugarswithout symptoms.

We were recently told ata clinic visit that ourchild should not be

given insulin just prior to a hotbath, shower or hot tub. Wouldyou please explain the reason forthis?

The hot bath or shower (or hot tub)increases the blood flow to the skin.As more blood flows to this area, more

insulin is rapidly taken up by the blood(probably primarily Humalog, NovoLog,Apidra or Regular insulins). This can thenresult in a severe low blood sugar. The answeris to always take the insulin after the hotshower or bath. The shower or bath shouldnot be taken in the 30-90 minutes afterHumalog/NovoLog/Apidra or in the fourhours after taking Regular insulin. This mayhelp to prevent a severe low blood sugar.

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Wait to take your shotafter a bath or shower.

pink panther - diabetes management - chapter 6

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