[Music] all right you guys welcome back to the next lesson in our series in which we are covering the endocrine system and in this lesson we're gonna be talking about the differences between hypoglycemia and hyperglycemia and for those of you who don't know my name is Eddie Watson and this is ICU advantage and if this is your first time to this channel and you'd be interested in seeing more in-depth critical care educational content such as this then please do subscribe to our channel below make sure though that you guys hit that Bell icon that way you'll be notified as soon as our new lessons become available to you as always I truly value the subscriptions the likes and the comments that you guys leave for us it really goes a long way to help support this channel and for that I want to thank you guys alright so with that out of the way let's go ahead and begin our lesson here like I said in this lesson we're gonna be talking about the differences between our hypoglycemia and our hyperglycemia and so what we're really talking about with this is we're dealing with irregularities in our body's glucose level and so our glucose level is either gonna be too low in the case of hypoglycemia or it's gonna be too high in the case of hyperglycemia but it's really all revolving around this molecule called glucose here and so really glucose is just a simple sugar it's got the chemical formula of c6 h-12 o-6 and it's the most abundant monosaccharide that's available that falls within this subcategory that we often know is carbohydrates and what's so special about glucose is that it is the primary energy source for our body and so the proper regulation and availability of glucose is gonna have a significant impact on the way our body functions and so let's go ahead and move in and start to talk about our hypoglycemia and so with hypoglycemia what we're dealing with is something that's resulting from the imbalance between our glucose production and our glucose utilization so we can almost think of it like a seesaw and here we have our production and here we have our utilization and as we can see our production is lower than what we're utilizing therefore we're gonna find ourselves in a state of a deficit of this glucose and if this deficit becomes significant enough that this can really be one of the more common and different emergencies that we're going to encounter especially within the ICU but really the way that we define this is if we have a blood glucose that is less than 60 and that's measured in milligrams per deciliter and so like we said over here glucose is that primary source of energy for our body and our brain really relies on this in order to function properly and so if our blood glucose drops below normal levels it can have pretty profound effects and if it gets low enough it can even lead to coma or possibly death so the important takeaway from this is that acute hypoglycemia can be fatal if it's left untreated so up next let's talk about some of the causes for hypoglycemia and there's really three subcategories that we can divide these causes up into the first of these is what we call endogenous the second of these is what we call exogenous and the third is what we call functional and so when we talk about these endogenous causes what we're really talking about are either tumors or metabolic errors and really what happens with these is we either see an overuse of glucose as a result or an overproduction of insulin as a result both of these leading to a state of having too little glucose now for hours Aegina scauses these are going to come from things like either having excessive insulin and this can either be from too much intake or the use of some sort of secreted ogz this can also be as a result of the use of oral anti-diabetic s' some drugs can also be the cause as well as potential the use of alcohol now when we talk about the functional causes there's a couple things that we can talk about here we can have things like excessive muscle use so think long continuous strenuous activity that our muscles are going to burn up that glucose or even something like prolonged seizure activity this can also come from hypermetabolic states and a really good example of this is something like sepsis where the body could be just overly utilizing glucose or you could also see this in something like dumping syndrome so if the body is just not able to process what is ingested quick enough in order to get the necessary energy from it that could also be a functional cause so like I said these are the things that could cause hypoglycemia but what are we gonna expect to see for signs and symptoms in our patients when they have hypoglycemia so really our signs and symptoms are going to be dependent on how severe the hypoglycemia is we can either see a mild hypoglycemia or we can see either a moderate or a severe hypoglycemia and so when we talk about the mild hypoglycemia the signs and symptoms are really going to be a result of seeing an ADD renner DIC response so this is where you can think of epinephrine glucagon glucocorticoids and growth hormone that are going to be released as a result of this hypoglycemia and this is where we're gonna see these symptoms originated from so these are things like diaphoresis tremors or shakiness tachycardia paresthesia pallor excessive hunger or even anxiety so think about things that you would expect to see with at adrenergic response now in the moderate severe side what we're dealing with here is some sort of CNS response so the central nervous system and really the result of this is because our brain is being depleted of glucose so here you could be seeing headache mood changes an inability to concentrate drowsiness confusion impaired judgment they could also have a staggering gait or slurred speech double vision they could even be experiencing psychosis or things could progress to even like we talked about seizures or coma and so we're really going to be seeing those profound effects as a result of that impairment of the CNS really the impairment of our brain and so really you can think about these symptoms as being related to that impairment and one interesting thing to know is that some of these symptoms will often mimic what you would see in a patient who is having a stroke and so this is why when we are suspecting our patient is possibly having a stroke one of the things we're gonna do is check a blood sugar because if they're hypoglycemic that could be what's causing these symptoms so how do we diagnose these patients well we had kind of hit on it already but our hallmark definition is gonna be a serum blood sugar with a value less than 60 now if their blood sugar is in the range of 20 to 40 that that's when we could potentially see seizures and for our severe hypoglycemia if we are less than 20 that's where our patients are oftentimes going to be in a coma and puts them at risk of death so these are the things that you want to be watching out for you want to be able to recognize these signs and symptoms because if we see these and we've run a test on their blood sugar and we see that they are hypoglycemic we need to look at what we're gonna do to treat them and really our best treatment is going to be our prevention and this is either going to come in the form of our monitoring that we're doing for our patients or in our recognition as well as our education for our patients for these signs and symptoms especially the mild early signs and symptoms so that they can catch this and resolve this quicker before progressing to either a moderate or more severe hypoglycemia but as far as the actual treatment that we have available to them the first primary form of treatment that we would do is we would give them 10 to 15 grams of glucose and so this is going to be some form of oral glucose this can either come in the form of a snack that they can take or oftentimes you'll see things like glucose gel that you can give to your patients now if after this initial dose of glucose they still remain hypoglycemic you want to repeat this in 10 minutes and from there we want to follow up with complex carbs so these are things like milk and cheese so this is really our best way of being able to treat these patients but depending on what's going on with them or how severe their hypoglycemia is we might not be able to treat them with oral glucose and so we need to find some other method of doing this and so there's two things that we can do to treat these patients the first is we can give them 1 to 2 milligrams of glucagon and this is something that we can give them either IV intramuscular or even subcutaneously and this glucagon is going to stimulate the liver to release glucose now the other option which I think will typically see more often in the ICU than glucagon is going to be administering a dose of IV dextrose and this is going to be 25 grams of a d50 solution and this is going to be done through an IV push so these are the ways in which we're going to treat this hypoglycemia and really the main purpose of this treatment is to provide the glucose to these patients that they're desperately needing all right so let's move on from here and talk about hyperglycemia so one thing that's important to know is that hyperglycemia and diabetes for that matter that it really carries a four-fold increase in morbidity and mortality for our hospitalized patients and so it's important that we can prevent these complications for our patients but it's also important to know that of our hospitalized patients that don't have a history of diabetes 12% of them will likely develop some sort of hyperglycemia while they're hospitalized and if our patient falls in this category they have a 18 times greater mortality when we compare them to diabetic patients so again it's really important that we are monitoring for this and intervening early in order to prevent this hyperglycemia in our patients but what makes this difficult for us is we're dealing with what's a natural metabolic response to acute illness or injury so simply the patient's being in our care are already going to be higher risk for these hyperglycemic events and the reason that we see this is as a result of our stress response we're gonna have the release of glucocorticoids catecholamines growth hormone and other cytokines and all of this is going to lead to the catabolism of fat and protein which is going to lead us to an elevation in our patients glucose levels so what are some of our causes for our patients experiencing hyperglycemia so the first set of things are things that we're going to see in our hospitalized patients things like M eyes strokes surgery trauma pain sepsis anything that's going to trigger that stress release in our patients and again that stress response is going to cause the release of those biological mediators and hormones and also with this the greater the stress that they experience the more the release and thus ultimately the higher the glucose level now the other big cause that I want to talk about for hyperglycemia is going to be our diabetes and it's important to know because this is the fourth most common comorbidity that we're going to encounter and when we're dealing with diabetes what we're dealing with is the inadequate uptake of glucose by their body's cells and this is ultimately going to lead to a state of hyperglycemia and the reason for this is going to come in two different forms something that we classify as our type 1 diabetes and our type 2 diabetes so our type 1 diabetes is primarily dealing with the production or the secretion of insulin by the pancreatic beta-cells type 2 diabetes is different because this is a lack of sensitivity of our insulin receptors in our body and so while the cause of this is different it altima telida the same thing the inability of those cells to uptake glucose to use in metabolism so we're going to talk about some of this a little bit more in the next lesson but I do want to hit on how we manage these patients in the ICU and so really our management of these critically ill patients is going to primarily revolve around two main things first is going to be our frequent blood glucose monitoring and the next is going to be our insulin management and typically this insulin management is going to be through a continuous IV infusion and so it is important to know that there is some controversy that exists related to how tight we should really be controlling our patient's blood glucose levels there are some studies that show a decrease in mortality with cardiac surgery patients if we keep these levels under a hundred and ten and this is even despite the increase in the rates of hypoglycemia as a result but then they also did the same study and looked at general medical ICU patients and they saw an increase in this mortality because of these hypoglycemic events and so oftentimes our goal is really going to be to keep our blood glucose less than 180 and this management is also going to change whether our patients are experiencing diabetic ketoacidosis or DKA or hyperosmolar hyperglycemic state or HHS and in fact the next lesson we're going to talk about the difference between these two all right so that pretty much was a good review of the differences between hypoglycemia and hyperglycemia and what are some of the things that we expect to see in these patients and ultimately how would we treat them both of these are very common things that you are going to encounter and the care of your patients in the ICU so it's important that you are able to identify and appropriately monitor and treat these patients and hopefully after this lesson you've got a better understanding in order to be able to do just that all right and so with that said that's gonna finish this lesson and I want to thank you guys so much for watching like I said I hope that you found this lesson useful and if you did please go down and hit the like button for us or leave us a comment and let us know it really goes a long way to help support us here like I said in the next lesson we're gonna take a look at the differences between DKA and HHS and what you would expect to see so make sure and subscribe to the channel to be notified when that lesson becomes available otherwise in the meantime make sure and check out the last series that we put together in which we did a good overview of heart failure all right you guys thank you so much for watching you guys have a wonderful day