Severe hypoglycaemia requiring the assistance of emergency medical services--frequency, causes and symptoms

Modifiable factors to prevent severe hypoglycaemic and diabetic ketoacidosis presentations in people with type 1 diabetes

AIMS

In tackling rising diabetes-related emergencies, the need to understand and address emergency service usage by people with type 1 diabetes is vital. This review aimed to quantify current trends in presentations for type 1 diabetes-related emergencies and identify public health strategies that reduce the frequency of diabetes-related emergencies and improve glycaemic management.

METHODS

Medline (OVID), Cochrane and CINAHL were searched for studies published between 2000 and 2023, focusing on people with type 1 diabetes, severe hypoglycaemia and/or diabetic ketoacidosis, and ambulance and/or emergency department usage. There were 1313 papers identified, with 37 publications meeting review criteria.

RESULTS

The incidence of type 1 diabetes-related emergencies varied from 2.4 to 14.6% over one year for hypoglycaemic episodes, and between 0.07 and 11.8 events per 100 person-years for hyperglycaemic episodes. Notably, our findings revealed that ongoing diabetes education and the integration of diabetes technology, such as continuous glucose monitoring and insulin pump therapy, significantly reduced the incidence of these emergencies. However, socio-economic disparities posed barriers to accessing these technologies, subsequently shifting the cost to emergency healthcare and highlighting the need for governments to consider subsidising these technologies as part of preventative measures.

CONCLUSIONS

Improving access to continuous glucose monitoring and insulin pump therapy, in combination with ongoing diabetes education focusing on symptom recognition and early management, will reduce the incidence of diabetes-related emergencies. Concurrent research assessing emergency healthcare usage patterns during the implementation of such measures is essential to ensure these are cost-effective.

Hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

People with diabetes mellitus commonly experience hypoglycemia, but they may not necessarily present to hospital after severe hypoglycemia requiring paramedic assistance. We sought to describe the incidence and characteristics of calls for hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada, and to determine predictors of hospital transport.

METHODS

This population-based retrospective cohort study used data extracted from ambulance call reports (ACRs) of 8 paramedic services of the Southwest Ontario Regional Base Hospital Program from January 2008 to June 2014. We described calls in which treatment for hypoglycemia was administered, summarized the incidence of hypoglycemia calls and performed logistic regression to determine predictors of hospital transport.

RESULTS

Out of 470 467 ACRs during the study period, 9185 paramedic calls occurred in which hypoglycemia treatment was administered to an adult (mean age 60.2 yr, 56.8% male, 81.1% with documented diabetes). Refusal of hospital transport occurred in 2243 (24.4%) of calls. Documented diabetes diagnosis (adjusted odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69-0.96), higher capillary blood glucose (adjusted OR 0.31, 95% CI 0.22-0.44) and overnight calls (adjusted OR 0.80, 95% CI 0.72-0.91) were associated with lower odds of hospital transport. Higher-acuity calls (adjusted OR 2.05, 95% CI 1.58-2.66) were associated with higher odds of transport. The estimated annual incidence rate of hypoglycemia requiring paramedic assistance was 108 per 10 000 people with diabetes per year.

INTERPRETATION

Hypoglycemia requiring paramedic assistance in southwestern Ontario is common, and close to 25% of calls do not result in hospital transport. Physicians managing diabetes care may be unaware of patients' hypoglycemia requiring paramedic care, suggesting a potential gap in follow-up care; we suggest that paramedics play an important role in identifying those at high recurrence risk and communicating with their care providers.

Emergency attendance for acute hyper- and hypoglycaemia in the adult diabetic population of the metropolitan area of Milan: quantifying the phenomenon and studying its predictors

BACKGROUND

We quantified, among diabetic adults, the frequency, costs, and factors associated with visits to the emergency department (EDs) and subsequent hospitalizations for acute hypoglycaemic and hyperglycaemic events.

METHODS

We included adults with diabetes residing in the Milan Agency for Health Protection between 2015 and 2017. From healthcare databases, we identified demographic variables, comorbidities, type of treatment, insulin treatment duration, previous ED attendances for acute glycaemic events, and two indicators of glycaemic monitoring. Using a validated ICD-9-CM coding algorithm, we identified all ED attendances for acute glycaemic events from the ED database and calculated their incidence. We computed the direct costs from health databases and presented them as average annual mean costs for those having had at least an ED attendance. The analysis of the association between the number of ED attendances and potential determinants was performed using zero-inflated negative binomial regression models. These two-part models concomitantly estimate two sets of parameters: the odds-ratios (ORs) of having no attendances and the incidence rate ratios (IRRs) of attendance.

RESULTS

The cohort included 168,285 subjects, 70% of subjects were older than 64 years, 56% were males, and 26% were treated with insulin. The incidence of acute glycaemic events for those attending the ED was 7.0 per 1000 patient-years, followed by hospitalization 26.0% of the time. The total annual direct cost for ED attendances due to acute glycaemic events was 174,000 €. Type of antidiabetic treatment had the strongest association with ED attendances for hypoglycaemia. Patients assuming insulin only had a lower probability of having no attendances (OR compared to those who assumed non-insulin antidiabetic drugs =0.01, 95% CI = 0.00-0.02). These patients also had the highest rate of hyperglycaemic episodes (IRR = 7.7, 95% CI = 5.1-11.7 for insulin only vs. non-insulin antidiabetic drugs). Subjects having had a previous episode of the same type leading to an ED visit had a higher rate of subsequent attendances (IRR for hypoglycaemia = 5.3, 95% CI = 3.9-7.3 and IRR for hyperglycaemia = 3.7, 95% CI = 1.3-10.2).

CONCLUSION

Insulin treatment and having had a prior acute glycaemic event leading to an ED visit were major predictors of ED attendance for hyper and hypoglycaemia in a population of adults with diabetes.

Pharmacotherapy as major risk factor of falls - analysis of 12 months experience in hospitals in South Bohemia

This study aimed to analyze the effect of fall risk-increasing drugs (FRIDs) and drug-related factors relative to falls through clinical pharmacy service in hospitalized patients, focusing on the relevance of clinical pharmacist evaluation in the context of physician assessment. A prospective study of inpatient falls was conducted in 2017 retrieving data from 4 hospitals in South Bohemia, Czech Republic. An online database was developed to collect patient and fall-related data, and fall evaluation records. Healthcare professionals classified the overall effect of drugs on falls using Likert scale. Univariate and multivariate correlations were performed with a significance level of p < 0.05. Out of the total 280 falls (mean age of patients 77.0 years), a mean of 2.8 diagnoses with fall-related risk, 8.8 drugs, and 4.1 FRIDs per fall were identified. Incidence of falls decreased quarterly (p < 0.001). Use of FRIDs were positively associated with increasing age (p = 0.007). Clinical pharmacists were more likely to identify pharmacotherapy as the relevant fall-related risk, compared to physicians evaluation (p < 0.001). An increasing total number of prescribed drugs as well as higher number of FRIDs increased the suspicion in both professionals in the context of drug-related causes of falls.

Risk factors for unstable blood glucose level: integrative review of the risk factors related to the nursing diagnosis

Objective

to identify evidence in the literature on the possible risk factors for the risk of unstable blood glucose diagnosis in individuals with type 2 diabetes mellitus, and to compare them with the risk factors described by NANDA International.

Method

an integrative literature review guided by the question: what are the risk factors for unstable blood glucose level in people with type 2 diabetes mellitus? Primary studies were included whose outcomes were variations in glycemic levels, published in English, Portuguese or Spanish, in PubMed or CINAHL between 2010 and 2015.

Results

altered levels of glycated hemoglobin, body mass index>31 kg/m2, previous history of hypoglycemia, cognitive deficit/dementia, autonomic cardiovascular neuropathy, comorbidities and weight loss corresponded to risk factors described in NANDA International. Other risk factors identified were: advanced age, black skin color, longer length of diabetes diagnosis, daytime sleepiness, macroalbuminuria, genetic polymorphisms, insulin therapy, use of oral antidiabetics, and use of metoclopramide, inadequate physical activity and low fasting glycemia.

Conclusions

risk factors for the diagnosis, risk for unstable blood glucose level, for persons with type 2 diabetes mellitus were identified, and 42% of them corresponded to those of NANDA International. These findings may contribute to the practice of clinical nurses in preventing the deleterious effects of glycemic variation.

A retrospective study on epidemiology of hypoglycemia in Emergency Department

BACKGROUND

Hypoglycemia is one among the leading causes for Emergency Department (ED) visits and is the most common and easily preventable endocrine emergency. This study is aimed at assessing the incidence and elucidating the underlying causes of hypoglycemia.

MATERIALS AND METHODS

A retrospective, observational study which included patients registering in ED with a finger prick blood glucose ≤60 mg/dl at the time of arrival. All patients aged above 15 years with the above inclusion criteria during the period of August 2010 to July 2013 were selected. The study group was categorized based on diabetic status into diabetic and nondiabetic groups.

RESULTS

A total of 1196 hypoglycemic episodes encountered at the ED during the study period were included, and of which 772 with complete data were analyzed. Underlying causes for hypoglycemia in the diabetic group (535) mainly included medication related 320 (59.81%), infections 108 (20.19%), and chronic kidney disease 61 (11.40%). Common underlying causes of hypoglycemia in nondiabetic group (237, 30.69%) included infections 107 (45.15%), acute/chronic liver disease 42 (17.72%), and malignancies 22 (9.28%). Among diabetic subjects on antidiabetic medications (n = 320), distribution over 24 h duration clearly reported two peaks at 8^th and 21^st h. The incidence of hypoglycemia and death per 1000 ED visits were 16.41 and 0.73 in 2011, 16.19 and 0.78 in 2012, 17.20 and 1.22 in 2013 with an average of 16.51 and 0.91, respectively.

CONCLUSION

Bimodal distribution with peaks in incidences of hypoglycemic attacks at 8^th and 21^st h based on hourly distribution in a day can be correlated with the times just before next meal. None of the patients should leave ED without proper evaluation of the etiology of hypoglycemia and the problem should be addressed at each individual level. Increasing incidence of death over the years is alarming, and further studies are needed to conclude the root cause.

GLUCAGON PRESCRIPTION PATTERNS IN PATIENTS WITH EITHER TYPE 1 OR 2 DIABETES WITH NEWLY PRESCRIBED INSULIN

OBJECTIVE

To describe glucagon prescription patterns in patients with type 1 (T1DM) or type 2 diabetes (T2DM) who received an initial insulin prescription.

METHODS

Retrospective analyses were conducted with data from Truven Health MarketScan databases to assess time to glucagon prescriptions: filled within 1.5 months after index date (early) or after 1.5 months postindex (nonearly). The index date was the date of first insulin prescription between January 1, 2009 and December 31, 2011; for T2DM, without an insulin prescription in the previous 6 months; for T1DM, diabetes diagnosis preindex or within 3 months postindex.

RESULTS

Analysis included 8,814 patients with T1DM and 47,051 with T2DM (49.3% and 2.4%, respectively) who had glucagon prescriptions filled. The median times to first glucagon prescription were 196 days (T1DM) and 288 days (T2DM). The rates of filling glucagon were highest in the first 1.5 months. The times to first hypoglycemia-related emergency room (ER) visit for T1DM and T2DM cohorts were initially similar for those with early glucagon versus nonearly glucagon prescriptions. After 10.8 and 2.5 months postindex, respectively, the percentage of hypoglycemia-related ER visits was lower for those with early glucagon prescriptions.

CONCLUSION

Glucagon prescriptions filled for patients with diabetes who are initiating insulin are low. Patients with T1DM who were younger and healthier filled glucagon prescriptions more often; patients with T2DM who were younger and sicker and had a higher percentage of hypoglycemia-related ER visit history filled glucagon prescriptions more often. Glucagon filled early was associated with a lower incidence of hypoglycemia-related ER visits.

National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations

IMPORTANCE

Detailed, nationally representative data describing high-risk populations and circumstances involved in insulin-related hypoglycemia and errors (IHEs) can inform approaches to individualizing glycemic targets.

OBJECTIVE

To describe the US burden, rates, and characteristics of emergency department (ED) visits and emergency hospitalizations for IHEs.

DESIGN, SETTING, AND PARTICIPANTS

Nationally representative public health surveillance of adverse drug events among insulin-treated patients seeking ED care (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project) and a national household survey of insulin use (the National Health Interview Survey) were used to obtain data from January 1, 2007, through December 31, 2011.

MAIN OUTCOMES AND MEASURES

Estimated annual numbers and estimated annual rates of ED visits and hospitalizations for IHEs among insulin-treated patients with diabetes mellitus.

RESULTS

Based on 8100 National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance cases, an estimated 97,648 (95% CI, 64,410-130,887) ED visits for IHEs occurred annually; almost one-third (29.3%; 95% CI, 21.8%-36.8%) resulted in hospitalization. Severe neurologic sequelae were documented in an estimated 60.6% (95% CI, 51.3%-69.9%) of ED visits for IHEs, and blood glucose levels of 50 mg/dL (to convert to millimoles per liter, multiply by 0.0555) or less were recorded in more than half of cases (53.4%). Insulin-treated patients 80 years or older were more than twice as likely to visit the ED (rate ratio, 2.5; 95% CI, 1.5-4.3) and nearly 5 times as likely to be subsequently hospitalized (rate ratio, 4.9; 95% CI, 2.6-9.1) for IHEs than those 45 to 64 years. The most commonly identified IHE precipitants were reduced food intake and administration of the wrong insulin product.

CONCLUSIONS AND RELEVANCE

Rates of ED visits and subsequent hospitalizations for IHEs were highest in patients 80 years or older; the risks of hypoglycemic sequelae in this age group should be considered in decisions to prescribe and intensify insulin. Meal-planning misadventures and insulin product mix-ups are important targets for hypoglycemia prevention efforts.