The sugar that just kept dropping...

[NewWayofLife]

Have any of you ever seen a patient with hypoglycemia that just dropping despite every intervention?

I have never seen anything like what I saw last noc. Pt known diabetic, reports a 2-3 day "stomach bug" with nausea, vomiting, and diarrhea. Normally takes regular insulin, set dose, Q AM, along with PO hypoglycemics. States yesterday AM, FS was in the 40's, skipped AM insulin and PO meds. States po food intake decreased, but adequate. Certainly able to take PO- watched him eat a sandwich and down quite a lot of OJ. Family called EMS later that day for FS in the 30's.

Given before arrival to floor,

2 tubes glucose gel

4 Glucose tabs

2 mg glucagon

2 amps D50 IV

IV D5 1/2 NS @ 100ml/hr

Boxed lunch

Upon arrival to floor (sometime late in evening) ... FS in the 90's. Stayed up there only about a couple of hours, then in the 30's again.

Given between 11-7

4 amps D50

2mg Glucagon SQ (in seperate doses)

16 OZ per hypoglycemia protocol

IV D10 @100ml/hr

Seemed as though he'd barely hit normal after D50 AND glucagon, but only stay there for about an hour or so!! Current thinking... either OD on oral hypoglycemics or insuloma??? Many labs still pending when I left.

What a night, though!! FSBS was checked between Q15m after interventions!! and Q1h when >70. Total FSBS's for shift >15. Have never spent so much time on blood sugar in my life! Despite all of this... FSBS@6AM-55!!! Pt was being transferred to PCU level of care from tele when I left.

I'm exhausted. I think MY blood sugar is low from running around so much!

[angel o' mercy]

Recently had a pt admit following BS of 30 while at home. Pt had some ESRD, missed dyalysis and apparently per the doc, PO anti glycemics built up in his system keeping his sugar dangerously low. He too would rebound after OJ etc. but than soon after would drop again. I didnt give it much thought at first about the possibility of that occuring, but it only takes one time to see something unusual to remember for the next time. Did your pt have any renal issues?

[Noryn]

I have seen this several times, especially with patients taking glucophage.

Glucophage should not directly cause hypoglycemia--even in an overdose (if they develop lactic acidosis from this then perhaps but even in that case the hypoglycemia wouldnt be coming directly from the Glucophage).

I agree with some others, your protocol really should have something that will last a bit longer. Did the doctor not want to try Octeotride?

[maryloufu]

maryloufu- actually, that was on a med/surg floor

Did you even meet your other patients?

[YellowFinchFan]

ah, on two counts....the patient in question is/was a dial. pt....and

the measurements...60-120 is considered normal fasting....150 and over i understand can interfer with cardiac conductivity...much under 50 many will start to show signs of hypo....

I've actually had two patients do this - one was as bad as you described - every 20 mins I believe I was pushing dextrose/checking BS - it was endless and he needed dialysis because his kidneys were failing, he was at the point where he (when he was lucid) and his family started to discuss making him an DNR - they finally did and it was comfort measures after a horrible day of keeping him stable......

Another patient several months later also had the same problem, again kidney failure - we finally were able to manage is hypoglycemic moments with diet/meds -

[Lorna Doon]

:bowingpur It was a few years ago, but I seem to remember a LOT of teamwork that night.

[MedSurgeNewbie]

Might sound a bit crazy but I have seen this, pt had taken a sulfonylura drug they have a heck of a half life glipizide - We did 4 amps of d50 had d10 running and it was a struggle to keep them in the 50's -

[TexasPediRN]

We had a baby not to long ago on our unit..BS was 5 on admit, couldnt get the sugar up..

Workup for all metabolic diseases done, you name it..

Final thought was the babysitter gave the baby lantus...

Dont know what came of the situation...

[nyapa, RN]

i've seen it before, but usually in someone in either liver failure or pretty severe sepsis.

i too have seen it in someone with liver failure as well. the only other time is with people who generally are non compliant with their diabetes, making it very difficult to work out a proper effective medication/insulin regime.

[ER06]

I heard of a pt doing this in our ED. It turned out he had a "superbug" and was also septic, hypoxic. Had pneumonia in three lobes, major consolidation in these areas. He wasn't even diabetic, but his glucose would drop below 50 several times. The 'superbug" or bacteria was "gobbling up" the glucose in his blood stream.

[withasmilelpn]

I had a LTC patient that did this. She even ate a sandwich. We would get her up to the 50's and then she would drop. We finally ended up giving her an IV bolus glucose while we waited for EMS. She ended up being admitted and by the way she was ESRD and Septic as well.

[GallopinGal48]

I used to have a patient who came to ER all the time, took a blast on her mom's insulin (this patient wasn't diabetic). Not saying this happened to you, but this girl loved the ambulance ride, the drama, and all the attention. She did this three, four times a year. Sometimes, she was in BIG trouble, near coma, near death.

[MedicalLPN, LPN]

Had a patient several weeks ago, not a known diabetic came onto our floor from the ED with a BS of 32 only had her for four hours before my shift was over but in that time I had given her 3 Amps of D50, SQ inj. of glucagon, so much OJ with sugar it wasn't even funny, plus she had an IV of D5 NS her BS would go up to 150 after the amp of D50 and within half an hour shoot back down into the 30's I was getting her accucheck q 30 mins plus paging the MD, plus I had 5 other pts one of which was a comfort care getting ready to pass. It was horrible, I kept asking the MD to transfer her to ICU but he said he "didn't feel that is needed at this time" Needless to say een though I only had her for four hours I was very frustrated by the end of the night. Never did find out what was going on with her. Very weird.