1

Hypoglycemia Management Page 1 of 4

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

PRESENTATION Note: Call MERIT team at any time if patient in apparent physical distress TREATMENT
Serum glucose < 70 mg/dL or
A
Able
following clinical signs and ● Initiate Hypoglycemia Clinical Parameter order
to eat/drink by Yes
symptoms of hypoglycemia in Perform the following STAT: ● Call provider team or on-call provider, as appropriate
Yes mouth?
patients with/without ● Vital signs and oxygen saturation
Glucose ● If patient is symptomatic without hypoglycemia:
hypoglycemic medications: ● Point of care (POC) glucose level No
2 < 70 mg/dL? ○ Call provider team or on-call provider, or MERIT team
● Diaphoresis ● Pause subcutaneous insulin pump
No as appropriate
● Shakiness/Trembling or IV insulin infusion, if present
○ Document interventions in electronic health record (EHR)
● Mental status changes See Page 2
● If patient is without symptoms and without hypoglycemia:
● Headache
○ Resume insulin pump or IV insulin infusion as indicated
● Hunger
○ Document interventions in EHR

● Repeat oral treatment up to total of three

treatments, whether with oral glucose nutritional Yes See Page 2
source2, if available, or with oral dextrose 40% Glucose
Give patient gel as per clinical parameter order and < 70 mg/dL?
15-20 grams of Yes ● Recheck POC glucose after 15 minutes of each
No See Box B
carbohydrates such as Recheck POC Glucose treatment
one of the following: glucose after < 70 mg/dL?
Oral glucose Yes ● ½ cup fruit juice 15 minutes ● Call provider team or
nutritional source3 ● ¾ cup non-diet soda on-call provider, or MERIT Repeat treatment starting
available? ● 1 cup milk No B team as appropriate
●
from Box A and
No Yes ● Document interventions
● Call provider team or
Patient remains in EHR on-call provider, as
Give patient 1 tube symptomatic? Yes
Implement Clinical appropriate
(15 g) of oral dextrose
Parameter: No Recheck
40% gel as per One-hour
Hypoglycemia POC
clinical parameter glucose
orderset glucose in ● Document hypoglycemic
order < 70 mg/dL?
1 hour No event and interventions
1
This algorithm applies to patients currently on or being admitted to Inpatient, Observation, Extended Recovery, and Overnight Recovery or in the PACU in EHR
2
If patient has an insulin pump and symptoms of hypoglycemia, ask patient to stop insulin infusion from the pump and notify Endocrinology-Diabetes
● Disposition per provider
provider per on call calendar. Refer to Insulin Pump Policy (#CLN1284).
3
Oral glucose nutritional source: juice, non-diet soda, milk Department of Clinical Effectiveness V8
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023
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Hypoglycemia Management Page 2 of 4
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

Note: Call MERIT team at any time if patient in apparent physical distress
C
Patient unable to eat ● For patients > 25 kg: ● For patients > 25 kg: dextrose 50%, 50 mL (25 grams) IV push
or drink by mouth or dextrose 50%, 25 mL (12.5 grams) over 1 minute followed by normal saline flush
hypoglycemic despite IV push over 1 minute followed by ● For patients 5 – 25 kg: dextrose 50% 1 mL/kg IV push over
3 oral treatments normal saline flush 1 minute followed by normal saline flush
● For patients 5 – 25 kg: ● For patients < 5 kg: dextrose 10%, 5 mL/kg IV push
dextrose 50% 1 mL/kg IV push over Recheck Yes
Implement Clinical ● Additionally, for patients < 25 kg, contact provider for dextrose
1 minute followed by normal saline POC glucose Glucose 10% normal saline IV fluid orders
Parameter:
flush and contact provider for after < 70 mg/dL?
Hypoglycemia
dextrose 10% normal saline IV fluid 15 minutes No
orderset Call provider team or on-call
orders
Yes ● For patients < 5 kg: provider, as appropriate
dextrose 10%, 5 mL/kg IV push and Yes
Able contact provider for dextrose 10% Patient remains
to obtain IV normal saline IV fluid orders symptomatic? Yes
access? No Recheck ● Document hypoglycemic
One-hour
POC glucose event and interventions
No Administer glucagon2 No
glucose < 70 mg/dL? in EHR
● For patients ≥ 25 kg, give 1 mg subcutaneously ● Disposition per provider
in 1 hour
● For patients < 25 kg, give 0.5 mg subcutaneously

● Call provider team or on-call provider, as appropriate and

Yes Document
Glucose ● If IV access present, repeat treatment starting at Box C ●
Recheck POC < 70 mg/dL or hypoglycemic
glucose after patient remains ● Call provider team or on-call event and
15 minutes symptomatic? provider, as appropriate and interventions
Recheck POC Yes in EHR
Glucose ● If IV access present, repeat
No glucose in ● Disposition per
< 70 mg/dL? treatment starting at Box C
1 hour provider
1
This algorithm applies to patients currently on or being admitted to Inpatient, No
Observation, Extended Recovery, and Overnight Recovery or in the PACU
2
Note: ● If glucagon is contraindicated, provider will indicate an alternate treatment plan
● In an emergency, satellite pharmacy will dispense glucagon without order Department of Clinical Effectiveness V8
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023
 Hypoglycemia Management Page 3 of 4
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

SUGGESTED READINGS
American Diabetes Association. (2023). Standards of Care in Diabetes – 2023. Diabetes Care, 46(Suppl. 1), S105-106. doi:10.2337/dc23-S002

Lowe, R. N., Williams, B., & Claus, L. W. (2022). Diabetes: How to manage patients experiencing hypoglycaemia. Drugs in Context, 11:2021-9-11. doi:10.7573/dic.2021-9-11

McCall, A. L., Lieb, D. C., Gianchandani, R., MacMaster, H., Maynard, G. A., Murad, M. H., … Wiercioch, W. (2023). Management of individuals with diabetes at high risk for
hypoglycemia: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 108(3), 529-562. doi:10.1210/clinem/dgac596

McEuen, J. A., Gardner, K. P., Barnachea, D. F., Locke, C. L., Backhaus, B. R., & Hughes, S. K. (2010). Cultivating quality: An evidence-based protocol for managing hypoglycemia.
American Journal of Nursing, 110(7), 40-45. doi:10.1097/01.NAJ.0000383933.45591.1c

MD Anderson Institutional Policy #CLN1284 – Insulin Pump Policy

Society of Hospital Medicine Glycemic Control Task Force. (2015). Workbook for Improvement: Improving Glycemic Control, Preventing Hypoglycemia, and Optimizing Care of the
Inpatient with Hyperglycemia and Diabetes. Retrieved from http://tools.hospitalmedicine.org/resource_rooms/imp_guides/GC/GC_Workbook.pdf

Tomky, D. (2005). Detection, prevention, and treatment of hypoglycemia in the hospital. Diabetes Spectrum, 18(1), 39-44. doi:10.2337/diaspect.18.1.39

Torres Roldan, V. D., Urtecho, M., Nayfeh, T., Firwana, M., Muthusamy, K., Hasan, B., … Murad, M. H. (2023). A systematic review supporting the Endocrine Society Guidelines:
Management of diabetes and high risk of hypoglycemia. The Journal of Clinical Endocrinology & Metabolism, 108(3), 592-603. doi:10.1210/clinem/dgac601

Department of Clinical Effectiveness V8

Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023
 Hypoglycemia Management Page 4 of 4
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

DEVELOPMENT CREDITS

This practice consensus algorithm is based on majority expert opinion of Hypoglycemia workgroup at the University of Texas MD Anderson Cancer Center.
It was developed using a multidisciplinary approach that included input from the following:

Core Development Team Leads

Victor R. Lavis, MD (Endocrine Neoplasia and HD)
Rodrigo Mejia, MD (Pediatrics)
Sonali Thosani, MD (Endocrine Neoplasia and HD)

Workgroup Members

Conor Best, MD (Endocrine Neoplasia and HD) Christine R. Raby, AS, BS, MSN, RN (Inpatient Nursing)
Katherine Cain, PharmD (Pharmacy Clinical Programs) Goley B. Richardson, MSN, RN, OCN (Nursing Administration)
Tennille Campbell, RN (Nursing) Lindsay Robusto, PharmD, BCOP (Pharmacy Clinical Programs)
Karen Chen, MD (Critical Care Medicine) Janet Smith, MSN, RN (Nursing)
Joylyn Estrella, MSN, RN, CNL (Nursing Administration) Lisa Triche, DNP, RN (Pediatrics - Patient Care)
Olga N. Fleckenstein, BS♦ Steven Waguespack, MD (Endocrine Neoplasia and HD)
Jessica Morrow, BS, RN (Nursing) Mary Lou Warren, DNP, APRN, CNS-CC♦
Tanner Moser, PharmD, BCPS (Pharmacy Clinical Programs) Annie Wilson, MSN, RN, CNL (Inpatient Nursing)
Joanne Opena, MSN, CMSRN, CNL (Inpatient Nursing)

♦
Clinical Effectiveness Development Team

Department of Clinical Effectiveness V8

Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023