Incidence and Causes of Iatrogenic Hypoglycemia in the Emergency Department

Abstract

IntroductionHypoglycemia is frequently encountered in the emergency department (ED) and has potential for serious morbidity. The incidence and causes of iatrogenic hypoglycemia are not known. We aim to describe how often the cause of ED hypoglycemia is iatrogenic and to identify its specific causes.MethodsWe included adult patients with a chief complaint or ED diagnosis of hypoglycemia, or an ED glucose value of ≤70 milligrams per deciliter (mg/dL) between 2009–2014. Two independent abstractors each reviewed charts of patients with an initial glucose ≤ 50 mg/dL, or initial glucose ≥ 70 mg/dL with a subsequent glucose ≤ 50 mg/dL, to determine if the hypoglycemia was caused by iatrogenesis. The data analysis was descriptive.ResultsWe reviewed the charts of 591 patients meeting inclusion criteria. Of these 591 patients, 99 (17%; 95% confidence interval, 14–20%) were classified as iatrogenic. Of these 99 patients, 61 (61%) cases of hypoglycemia were caused by insulin administration and 38 (38%) were caused by unrecognized malnutrition. Of the 61 patients with iatrogenic hypoglycemia after ED insulin administration, 45 and 15 patients received insulin for hyperkalemia and uncomplicated hyperglycemia, respectively. One patient received insulin for diabetic ketoacidosis.ConclusionIn ED patients with hypoglycemia, iatrogenic causes are relatively common. The most frequent cause was insulin administration for hyperkalemia and uncomplicated hyperglycemia. Additionally, patients at risk of hypoglycemia in the absence of insulin, including those with alcohol intoxication or poor nutritional status, should be monitored closely in the ED.

Current and future therapies to treat impaired awareness of hypoglycemia

“…With better glycemic control, patients with Type 1 (T1D) and insulin-dependent Type 2 Diabetes (T2D) have been able to reduce the risk for diabetes complications (e.g., retinopathy, neuropathy, and nephropathy) ( Holman et al, 2008 ; Diabetes, 2016 ). Yet, as patients intensify glycemic control, the risk for iatrogenic hypoglycemia increases proportionately ( Holman et al, 2008 ; Lipska et al, 2014 ; Diabetes, 2016 ; Chittineni et al, 2019 ). From 1999 to 2011, there has been a trend in reduced hospitalizations for hyperglycemia, but the rates of hospital admissions for severe hypoglycemia remain almost two-fold higher than those for hyperglycemia ( Lipska et al, 2014 ).…”

Reducing the harm associated in treating hyperkalaemia with insulin and dextrose

“…Insulin/dextrose treatment can be complicated by hypoglycaemia (serum glucose <4.0 mmol/L) in 6–21% of people following treatment. 1 , 2 , 3 , 4 , 5 , 6 , 7 Hypoglycaemia poses significant risk to patients, including increased risk of seizures, neurological symptoms and cardiac instability, with associated morbidity and ultimately mortality. 5 The risk of hypoglycaemia is greatest in those with low body mass and impaired renal function.…”

“… 1 , 2 , 3 , 4 , 5 , 6 , 7 Hypoglycaemia poses significant risk to patients, including increased risk of seizures, neurological symptoms and cardiac instability, with associated morbidity and ultimately mortality. 5 The risk of hypoglycaemia is greatest in those with low body mass and impaired renal function. 3 , 4 , 8 The precise window following insulin/dextrose in which hypoglycaemia occurs remains debated; as a result, blood glucose monitoring varies across institutions.…”

Predicting hypoglycemia after treatment of hyperkalemia with insulin and glucose (Glu-K60 score)

“…Also, hypoglycemia can cause psychological symptoms such as anxiety or even coma and death. Moreover, hypoglycemia can give rise to non-medical complications, which are the causes of a patient's stress, such as increased healthcare costs and length of stay [ 14 ]. However, there was no available predictive score to predict hypoglycemia after treating hyperkalemia with insulin and glucose.…”