Key messages

• Given the wide range of 'normal' blood glucose values, diagnosis of pathological hypoglycemia depends on the clinical recovery from neuroglycopenic symptoms after an intravenous infusion of glucose.

• Glucose 25 g given intravenously (50 ml of 50 per cent glucose) usually reawakens a comatose hypoglycemic patient in 5 to 10 min.

• Intramuscular glucagon (1 mg) is an effective and portable alternative to intravenous glucose for the majority of hypoglycemic episodes in insulin-dependent diabetics.

• In the malnourished, thiamine deficiency will be accelerated if circulating glucose substrate is rapidly restored, causing acute and potentially fatal Wernicke's encephalopathy.

• Prolonged hypoglycemia, particularly in association with hypoxemia and hypotension, leads to cerebral edema. Recovery may be delayed despite the attainment of normoglycemia.

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