From the situation of 37 patients admitted to hospital due to hypoglycemia
Hypoglycemia is a group of clinical syndrome caused by low plasma glucose concentration and mainly characterized by sympathetic excitation and glucose deficiency in brain cells, with high morbidity, and untimely treatment may endanger patients’ lives. The clinical data of 37 cases of hypoglycemia patients admitted to our hospital from January 2001 to January 2011 were retrospectively analyzed and summarized as follows: Jiang Zhaoshun, Department of Endocrinology, General Hospital of Jinan Military Region
1. Clinical data
1.1 General information of patients
A total of 37 patients were enrolled in this data, including 16 males and 21 females, aged from 23 to 88 years old, with an average of 58±18.7 years old. There were 19 cases with a clear history of diabetes mellitus (1 case of type 1 diabetes mellitus), 18 cases with hypertension, 11 cases with coronary heart disease, 10 cases with cerebral infarction, 5 cases with renal insufficiency, 3 cases with cancer surgery, and 1 case with pituitary tumor. There were 9 cases with a history of smoking and 8 cases with a history of alcohol consumption.
1.2 Diagnostic criteria
Diagnostic criteria of hypoglycemia [1]: According to the typical manifestations of hypoglycemia (Whipple’s triad), it can be determined that: ① hypoglycemic symptoms; ② blood glucose is lower than 2.8 mmol/l at the time of attack; ③ hypoglycemic symptoms can be rapidly relieved after sugar supply. A small number of patients whose fasting blood glucose is not obviously reduced or in non-episode period should be tested several times for the presence of fasting or post-absorption hypoglycemia, and if necessary, 48~72 hours fasting test should be used; diabetic patients receiving drug treatment belong to the category of hypoglycemia as long as their blood glucose level is ≤3.9mmol/l [2].
1. 3 Clinical manifestations
Hypoglycemia takes sympathetic hyperexcitation and brain dysfunction as the main clinical manifestations. In the data of this group, there were 18 cases (48.65%) of sympathetic excitation symptoms such as palpitation, chest tightness, anxiety, sweating, hunger, hand trembling and general weakness, and 19 cases (51.35%) of central nervous manifestations such as dizziness, headache, blurred vision, unconsciousness, irritability, coma and even neuropsychiatric symptoms such as seizure. Among them, 1 case was accompanied by transient slurred speech, 6 cases were accompanied by limb convulsions (2 cases were misdiagnosed as epilepsy in the primary hospital), 3 cases were irritable and 4 cases were unconscious.
1.4 Causes of hypoglycemia (see Table)
Table: Distribution of causes of hypoglycemia
Cause
Number of cases
Percentage (%)
Diabetic patients
19 cases
Inappropriate oral hypoglycemic medication
Failure to eat normally after taking sulfonylurea hypoglycemic drugs
5
13.5
51.35
Proprietary Chinese medicines and health products of unknown origin and composition
4
10.81
Taking sulfonylurea hypoglycemic drugs with renal insufficiency
2
5.41
Long-term use of phenelzine hydrochloride
1
2.70
Inappropriate use of insulin
Failure to eat or reduced eating after insulin injection
3
8.11
Overdose of insulin
2
5.41
With acute gastroenteritis, vomiting and reduced eating
2
5.41
Non-diabetic patients
18 cases
Insulinoma
7
18.92
48.65
Hyperinsulinemia suspected islet B-cell hyperplasia
2
5.41
Reactive hypoglycemia
5
13.51
Hepatogenic hypoglycemia
1
2.70
Left heart failure combined with upper gastrointestinal bleeding
1
2.70
Cause unknown (1 case after thyroid cancer surgery)
2
5.41
1.5 Laboratory tests
All patients had hypoglycemic episodes with blood glucose between 0.2 and 3.6 mmol/l, with a mean of (2.22 ± 0.77) mmol/l. Among the diabetic patients, 1.2 to 3.4 mmol/l, with a mean of (2.18 ± 0.59) mmol/l, and glycosylated hemoglobin between 5.7% and 12.2%.
1.6 Treatment observation
Blood glucose was tested immediately at the onset of the attack and glucose supplementation was actively given. In mild to moderate cases, 50% glucose was given orally, and in severe cases, 50% glucose 60-100 ml was immediately pushed intravenously, followed by 10% glucose solution intravenously until the patient became conscious and the blood glucose returned to normal level, with dexamethasone drip added if necessary. Blood glucose was monitored regularly and tracked for at least 24-48 hours, and all patients’ hypoglycemic symptoms were relieved. Six cases with insulinoma were cured by surgery, and one case was not operated at an older age and was maintained with oral sugar water several times a day.
2 Discussion
Hypoglycemia is a common clinical emergency with complex etiology. Long-term recurrent hypoglycemia can induce cerebrovascular accident and/or myocardial infarction, which can lead to death in serious cases. There are many causes of hypoglycemia. In this paper, we analyzed the clinical data of 37 cases of hypoglycemia patients who were admitted to our hospital with hypoglycemia diagnosis in the past 10 years, and the main causes are insulinoma, pharmacogenic hypoglycemia, reactive hypoglycemia, heart, liver and kidney failure, acute infection and insufficient dietary intake. Among them, pharmacogenic hypoglycemia mainly occurs in diabetic patients. Insulinoma is the most common cause of organic hypoglycemia, and the tumor is mostly located in the pancreas. Insulinoma can be familial and can coexist with parathyroid adenoma and pituitary tumor (one patient had a coexisting pituitary tumor), and surgical resection is the main treatment for this disease. In addition, the literature reports that diabetic gastroparesis can also lead to hypoglycemia, mainly related to impaired gastric motility, delayed gastric emptying affecting the emptying of food and the pharmacokinetics of hypoglycemic drugs, so that food absorption and insulin, especially autologous insulin secretion timing cannot be physiologically synchronized [3].
Diabetes mellitus is an important risk factor for the development of hypoglycemia. Currently, large clinical studies such as the DCCT and UKPDS have shown that strict glycemic control significantly reduces the occurrence of chronic vascular complications of diabetes mellitus. However, strict glycemic control increases the occurrence of hypoglycemia significantly. Studies have shown that intensive insulin therapy increases severe hypoglycemia threefold [4]. The 19 cases of hypoglycemia with diabetes mellitus in this data, amounting to 51.35%, have become the most important cause of hypoglycemia. Among them, there were 11 cases of improper use of oral hypoglycemic drugs (4 cases of taking proprietary Chinese medicines and health products of unknown origin and composition by themselves; 1 case of taking phenylephrine hydrochloride; 4 cases of not eating normally after taking sulfonylurea hypoglycemic drugs, and 2 cases with renal insufficiency), and 5 cases of unreasonable application of insulin (2 cases of insulin overdose, 3 cases of not eating normally or eating less after insulin injection). Pharmacogenic hypoglycemia is the main cause of hypoglycemia in diabetic patients.
Age is also an important risk factor for the occurrence of hypoglycemia, and the age of patients in this data ranged from 23 to 88 years, with the elderly being the most common (18 cases in those older than 60 years). Some studies have shown [5] that the incidence of hypoglycemia in elderly diabetic patients has a tendency to increase with increasing age. The high incidence of hypoglycemia in elderly patients may be related to the following reasons: (1) the poor regulation function of the body in the elderly, insensitivity to hypoglycemia, when blood glucose is low, the phytoconiosis cannot excite the sympathetic nerve and cannot secrete the blood glucose raising hormone in time; (2) the response of the elderly to glucagon and adrenaline is reduced; (3) with age, the physiological function of the liver and kidney of the elderly decreases, and the hepatic glucose allogenic function is reduced. There is not enough glycogen to be converted into blood sugar when hypoglycemia occurs. Decreased glomerular rate filtration decreases the clearance rate of insulin and hypoglycemic drugs, which increases the risk of hypoglycemia; ④ elderly patients have poor compliance in taking medication, decreased memory, insufficient knowledge of hypoglycemic drugs, and are prone to increase the dose or type of hypoglycemic drugs without authorization.
⑤ In this data, there were 4 cases of hypoglycemia caused by self-administration of proprietary Chinese medicines and health care products of unknown source and composition, accounting for 36.36% of all patients with improper use of oral hypoglycemic drugs, and all 4 cases were elderly diabetic patients (age 72-80), all of them were cases in the past 3 years, and they did not know enough about the causes and hazards of hypoglycemia and the characteristics of hypoglycemic drugs, and were easy to listen to the false propaganda of unlawful elements and They are prone to listen to the false propaganda of unscrupulous elements and blindly buy “natural drugs” or “health care products” of unknown origin and composition to lower sugar, which not only delay the disease, but also easily lead to hypoglycemia and other emergencies, endangering life safety. Therefore, it is suggested that nowadays, with the increasing number of advertising products, clinicians should strengthen the extensive publicity and education on diabetes and hypoglycemia for diabetic patients, especially elderly diabetic patients, to improve their awareness of the disease and take scientific prevention and control measures, which are necessary to reduce the occurrence of hypoglycemia in diabetic patients.