D50 for blood glucose protocol vs juice/snacks, your thoughts

[Billy_Ruben]

I had a pt, who I had taken care of for a few days and was familiar with, that had a low blood sugar when I was coming onto my shift. His reading was 63 and he has a habit of getting low but being asymptomatic. Apparently, the day shift nurse had the same level of concern (not hugely worried) that I had. She was pretty much monitoring and supplementing with snacks.

This pt was on isolation precautions and had several issues that I was on the phone with the doctor and lab about. We needed blood cultures and to start a new abx. I had to wait for lab to come to get the culture before I could begin the new antibiotic. The order was to get one from his portacath and one peripheral and if unable to obtain form the portacath (which I knew would happen as his pc didn't return) then two peripherals.

So, I was trying to group his care d/t his being on isolation. After all was said and done, I ended up getting the new antibiotic going (late because lab was dragging their feet) and after it was running I discovered his blood sugar was 46. Now, by this time, I had been in his room for about 30 minutes and still had things to do (drsg changes,etc). I knew good and well that the protocol was to give d50 by IV but he was completely asymptomatic. I decided to give him juice and crackers, let him eat that while I was doing the other stuff and recheck the blood sugar and if it was still low go for the d50.

My rational for this was:

1. He was asymptomatic and the juice and crackers may do just fine. I'd be in the room with him monitoring him the whole time.

2. Why stop the abx, even if just for a brief time unless absolutely necessary PLUS unhooking the abx and opening up that central line= more opportunity for infection.

3. This one is sort of selfish: I could call out and have someone bring me the snacks which frees me from having to ungown and regown.

4. He has a history of getting pretty low but comes right back up.

Well, he did just fine with the juice and crackers. His blood sugar was near 80 within fifteen minutes. I felt like I made a decent choice based on good rationales. However, when giving report to the oncoming nurse, the nurse flipped out. They were incredibly concerned that I did not follow protocol. Now I'm second guessing my decision.

I'm a new nurse with just at a year under my belt. I'm open to any tips, criticisms, etc. I really just want to learn and do what is right and in the best interest of my pts.

What do you think? Was I totally out of line? Should I have just followed the protocol?

Well, you're generally wise to follow protocols because that's what they're there for... and you're going out on a limb if you disregard them.

That said, you're always better to feed people for hypoglycemia than to hit their poor veins with the very acidic D50.

Of course, you had a central line so the acidity and veins weren't an issue (and stopping the abx for a couple of minutes won't hurt anything).

Be careful about some of your assumptions:

- "I'd be in the room with him the whole time." --- yep, right up until something unexpected came up (code, fall, and you ended up being gone for 30 minutes

- "Has a history of tolerating it (low BS)" -- yep, right up until he doesn't... and that would be the time that you discovered that your lines were crapped out and there was no glucagon to be had...

You could do that 1,000 times and be fine but it's number 1,001 that will get you and your patient into trouble.

When the BS was 60, it was time to deal with it as a high priority because swings in blood sugar are detrimental to the patient over the long term (that is, correlated with poorer outcomes).

Whenever you deviate from the physician's orders, you're taking a risk. In this case, the risk was rather small but also completely unnecessary (though not worth 'flipping out').

[psu_213, BSN, RN]

First, as was previously mentioned, always follow the protocol. I don't have my hospital's protocol memorized, but I believe that a BG of 46 is always treated with D50 if they have IV access. If the protocol calls for D50, give it. If you don't follow it, and there is a negative outcome for the pt, you will be in some very deep doo-doo. I don't think it's right for the next nurse to "flip out" about it...there is a more proper way to 'correct' you...however, she did have the right idea.

Also, go in right away and deal with the blood sugar. 5 more minutes is not going to make a big difference when it comes to starting the antibiotic--it could make a difference with the BG. Get the blood sugar squared away, then go back to worrying about the ABX.

[Billy_Ruben]

Well, you're generally wise to follow protocols because that's what they're there for... and you're going out on a limb if you disregard them.

That said, you're always better to feed people for hypoglycemia than to hit their poor veins with the very acidic D50.

Of course, you had a central line so the acidity and veins weren't an issue (and stopping the abx for a couple of minutes won't hurt anything).

Be careful about some of your assumptions:

- "I'd be in the room with him the whole time." --- yep, right up until something unexpected came up (code, fall, and you ended up being gone for 30 minutes

- "Has a history of tolerating it (low BS)" -- yep, right up until he doesn't... and that would be the time that you discovered that your lines were crapped out and there was no glucagon to be had...

You could do that 1,000 times and be fine but it's number 1,001 that will get you and your patient into trouble.

When the BS was 60, it was time to deal with it as a high priority because swings in blood sugar are detrimental to the patient over the long term (that is, correlated with poorer outcomes).

Whenever you deviate from the physician's orders, you're taking a risk. In this case, the risk was rather small but also completely unnecessary (though not worth 'flipping out').

Thanks. You mentioned some things I hadn't thought through.

[DSchulte99]

Like they said follow protocol. Whenever I break that due to judgement I let doc know and document it. Our protocol says to treat with d50 only if unresponsive. Otherwise orally. Could be a chance for you to bring it up to the committee to change it.

[blondy2061h, MSN, RN]

No matter how asymptotic a patient is with a BG, it's still impacting their body. Your patient was experiencing hypoglycemia unawareness which is relatively common in long standing diabetics with frequent lows. It makes hypoglycemia more dangerous not less dangerous. If your patient was treated for the 60 then dropped right down even lower it sounds like the food wasn't working too well. That said, I don't like D50 if its avoidable because it shoots people's BG's way up quickly then doesn't last long.

[Billy_Ruben]

I feel like I made a bad choice now. It bugs me that I felt confident in my decision until it was challenged.

...the juice and crackers may do just fine

BTW, patients who are slowly slipping down the glucose slope generally should be given protein and complex carbs rather than juice and crackers which are only a step away from a teaspoon of sucrose or a candy bar.

In other words, whole milk and a turkey sandwich is much preferred over OJ and crackers.

[Billy_Ruben]

BTW, patients who are slowly slipping down the glucose slope generally should be given protein and complex carbs rather than juice and crackers which are only a step away from a teaspoon of sucrose or a candy bar.

In other words, whole milk and a turkey sandwich is much preferred over OJ and crackers.

He did have peanut butter with it.

I feel like I made a bad choice now. It bugs me that I felt confident in my decision until it was challenged.

That's how you improve... be open to criticism and learn from those who've gone before.

Don't beat yourself up over it, just tweak your judgment.

Even very experienced nurses (and docs for that matter) make bad choices... they're usually not too open to being critiqued, though.

It's all good... no harm, no foul.

[blondy2061h, MSN, RN]

Ultimately the patient is okay, so that's the important part.

[psu_213, BSN, RN]

I feel like I made a bad choice now. It bugs me that I felt confident in my decision until it was challenged.

Just remember, no one who replied is trying to make you feel bad or to wreck your confidence. I have been a nurse for 5 years now...I have situations at work everyday that, when looking back on them, I would handle differently. I also realize that hindsight is 20/20. Just by coming here and positing about this, it tells me that you want to learn and want to get better, and that speaks volumes for you commitment as a nurse and your desire to become a better nurse.