Aims Neonatal hypoglycaemia is a leading cause of admission of term babies to the neonatal unit (NNU).1 Intravenous glucose solutions are used as a treatment strategy for patients with severe hypoglycaemia or patients that do not respond to enteral treatment. Varying concentrations of glucose including 10%, 12.5%, 15% and 20% are used for this treatment with ≥15% only used via a central line. 10% and 20% glucose solutions are commercially available as pre-made bags, though 12.5% and 15% solutions are prepared at the bedside. We aimed to review prescribing practice for neonatal hypoglycaemia in infants requiring ≥12.5% glucose and its impact on the patient’s NNU course.
Methods Patients admitted to our tertiary NNU with hypoglycaemia between January 2018 and December 2018 inclusive were identified using an admission database. Patient information was retrospectively collected using Digital Health Records. Glucose requirements were reviewed, and patients requiring >10% glucose for hypoglycaemia treatment were identified. Subsequently, patients who died, received part of their care outside the Trust, were fluid restricted, received parenteral nutrition or had an alternative underlying diagnosis for hypoglycaemia such as a genetic or mitochondrial disorder were excluded. For included patients, a designated set of parameters including demographics, medical diagnoses, risk factors for hypoglycaemia, glucose load and fluid volumes were collected.
Results In total, 210 patient hypoglycaemic episodes were identified, of which 26 patients required treatment with ≥12.5% glucose. Further exclusion against the defined criteria left 15 patients for review. The median number of risk factors for hypoglycaemia were 3, the most common being maternal labetalol use in pregnancy. Of the 15 included patients; 8 required 12.5% glucose (Group A), and 7 required escalation to 15% or 20% concentrations (Group B). 9/15 required a 2.5 ml/kg glucose bolus with the average length of time spent below <2.6 mmol/L of 7 hours. Glucose load was highest in Group B (15.39 mg/kg/minute) vs Group A (9.90 mg/kg/minute), p=0.0013, and a higher glucose load was associated with an increased length of time on intravenous fluids. Of the patients requiring >12.5% glucose, the median time to escalate from 12.5% to a higher concentration was 14.4 hours. Escalation of glucose enabled a reduction in intravenous glucose volumes. Patients who had escalation of treatment from 12.5% to 15% (n=3) had a median duration of intravenous fluid therapy of 14 days, compared to 5 days when escalating from 12.5% to 20% (n=4). 2 patients required re-escalation of treatment back to a higher glucose concentration; both had an underlying diagnosis of congenital hyperinsulinism. 8/15 patients had central access sited, consisting of 13 line insertions, with a complication rate (i.e. incorrect position or not working) of 31% (n=4).
Conclusion A small proportion of neonates with hypoglycaemia require escalation of intravenous fluids to ≥12.5% glucose to achieve normoglycemia. When this escalation is required, prompt central line insertion should be considered to avoid delay and allow for administration of ≥15% glucose. Ongoing work with the Neonatal Pharmacy Team aims to reduce the length of hypoglycaemic episodes and shorten treatment duration for babies.
Deshpande SU, M; Hawdon, J.M. Admissions of term newborn infants for hypoglycaemia: their characteristics and preventability. The Neonatal Society; 2016
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