Current practice of hypoglycemia management in the ED.
OBJECTIVE
To characterize hypoglycemia management and identify characteristics associated with refractory (need for additional treatment following initial management) and recurrent (adequate initial treatment followed by blood glucose [BG] ≤50 mg/dL) hypoglycemia.


METHODS
Retrospective review of adult emergency department (ED) patients who presented to a large academic medical center with hypoglycemia (BG ≤ 50 mg/dL) between January 2011 and July 2015. Data collection focused on BG measurements and treatment practices. Data are reported using descriptive statistics, Wilcoxon rank sum, and χ2analysis as appropriate.


RESULTS
Two hundred forty-four patients were included (mean age, 59 ± 18.7 years; weight, 85 ± 24.3 kg). Patients arriving via prehospital care (n = 124) were assessed faster in the ED (median, 25 minutes; interquartile range [IQR], 10-40 minutes) compared with ambulatory arrival (median, 43 minutes; IQR, 17-95 minutes; P = .0018). There were 174 patients with a BG ≤ 50 mg/dL in the ED. Of those, 108 (62.1%) were treated with intravascular bolus dextrose/intramuscular glucagon and 21 patients (12%) did not receive any treatment or food. The overall median time to treatment after identification of hypoglycemia was 12 minutes (IQR, 6-27.8 minutes); treatment was administered faster after bedside point-of-care testing assessment compared with when serum samples resulted (11 [IQR, 6-23.5] minutes vs 25 [IQR, 10.75-42.5] minutes, respectively; P = .015). The overall time to repeat BG was obtained 22 (IQR, 8-44) minutes after bolus treatment, but this interval increased with subsequent measurements. Refractory or recurrent hypoglycemia occurred in 30.3% of patients. Mean initial BG was lower in the subset of patients who developed refractory hypoglycemia compared with those who did not (35.1 ± 9.8 vs 37.6 ± 10.2 mg/dL, P = .079), although not statistically significant. Patients with recurrent hypoglycemia were also less likely to receive dextrose containing intravenous fluids compared with those without recurrent hypoglycemia (P = .028). Infection was the only associated characteristic with refractory or recurrent hypoglycemia (P = .021).


CONCLUSIONS
Overall, 12% of patients did not receive treatment for hypoglycemia in the ED with a BG ≤ 50 mg/dL. Time to treatment after identification was faster when identified by care testing vs serum sample result. Time to repeat BG in the ED was relatively quick, but did increase over time. About one-third of patients had refractory or recurrent hypoglycemia and infection was associated with this occurrence. Lack of dextrose containing intravenous fluid was associated with the incidence of recurrent hypoglycemia.
Department of Pharmacy, University of Rochester Medical Center, Rochester, NY.
Matthew H
MH
Bilhimer
Department of Pharmacy, University of Rochester Medical Center, Rochester, NY.
Cierra N
CN
Treu
Department of Pharmacy, University of Rochester Medical Center, Rochester, NY; Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 638, Rochester, NY 14642. Electronic address: nicole_acquisto@urmc.rochester.edu.
Nicole M
NM
Acquisto
D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000032:analysis; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000188:drug therapy / Q000453:epidemiology; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D005260:Female; D005934:Glucagon / Q000627:therapeutic use*; D005947:Glucose / Q000627:therapeutic use*; D006728:Hormones / Q000627:therapeutic use*; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D007004:Hypoglycemic Agents / Q000009:adverse effects; D015994:Incidence; D007239:Infections / Q000453:epidemiology; D007273:Injections, Intramuscular; D007275:Injections, Intravenous; D007328:Insulin / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D000067716:Point-of-Care Testing; D012008:Recurrence; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology; D012189:Retrospective Studies; D013549:Sweetening Agents / Q000627:therapeutic use*; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
D001786:Blood Glucose; D006728:Hormones; D007004:Hypoglycemic Agents; D007328:Insulin; D013549:Sweetening Agents; D005934:Glucagon; D005947:Glucose