Background: Hospitals generally have clear protocols, often nursing driven, for management of inpatient hypoglycemia. The American Diabetes Association recommends a standardized approach to hypoglycemia management in the hospital to address hypoglycemia. A frequent cause of hypoglycemia is poor management of the first hypoglycemia episode. Standard treatment protocols include the use of oral carbohydrate agents for patients who are awake, IV D50 for patients who can’t eat and have IV access, or glucagon intramuscular for those patients without IV access. Many protocols include the general rule of thumb that 15 grams of carbohydrates raises the glucose by 50 mg/dl within 15 minutes. Hence most protocols use 15 grams of oral carbohydrates, and use 25 ml of 50% dextrose, which equates to 12.5 grams of carbohydrates, regardless of the severity of hypoglycemia. In addition, protocols aim for the resolution of hypoglycemia (>80 mg/dl). We evaluated the effect of oral carbohydrate or IV D50 on hypoglycemia in the hospital.

Methods: Glucommander is an FDA cleared insulin management software for use in the hospital setting, with an IV insulin and a subcutaneous insulin module. When glucose is < 70 mg/dl, Glucommander provides a precise dosing recommendation for the D50 treatment based on the glucose, aiming for a target of 100 mg/dl. For oral treatments, the recommended dose is 15 grams of carbohydrates, regardless of the glucose level. Retrospective data was analyzed from all patients on Glucommander from January 1, 2017, to June 1, 2021, who experienced a reading < 70 mg/dl. If another reading >80 mg/dl occurred within 5 minutes, the subsequent result was excluded. If the subsequent reading was done within 45 minutes, the hypoglycemia treatment documented by nursing and the subsequent eligible glucose reading were recorded. The groups were divided by treatment: D50 or oral carbohydrates.

Results: 57,629 events < 70 mg/dl occurred that met our parameters. The treatment of hypoglycemia in 27,694 of these events was managed with D50 and in 29,935 events with oral carbohydrates. In the D50 group, 89.4% subsequent readings were >70 mg/dl, with a median next glucose of 100 mg/dl. In the oral carbohydrate group, 67.5% subsequent BG readings were >70 mg/dl, with a median next BG of 79 mg/dl. In the severe hypoglycemia group (< 40 mg/dl), 311 patients were managed with D50, with 82.1% of subsequent BGs >70 mg/dl; 577 patients had a reading < 40 mg/dl managed with oral carbohydrate, and 34.5% had a subsequent reading >70 mg/dl.

Conclusions: D50 IV treatment for hypoglycemia, with a dose related to the degree of hypoglycemia, was highly effective in managing hypoglycemia, with almost 90% achieving target blood glucose at the time of repeat. For more severe hypoglycemia (< 40 mg/dl) who were given 15 grams of carbohydrates, half of the patients remained < 80 mg/dl at repeat. We suggest that D50 IV treatment for hypoglycemia be given based on precise dosing relative to the degree of hypoglycemia, such as using a computerized dosing algorithm. For patients who consume oral carbohydrates to manage hypoglycemia, 15 grams is insufficient for most readings < 40 mg/dl and increasing that amount may be needed.

IMAGE 1: D50 Treatment

IMAGE 2: Oral Carbohydrate Treatment