Fluctuating Blood Sugar?

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Specializes in Cardiac, Acute/Subacute Rehab.

I need some help understanding the physiology of this...

Pt has widely varying blood sugars over 24 hour period. 300+ to 30s and 40s in late afternoon and early morning...no Lantus to speak of, and sliding scale coverage ordered ac&hs...eating well at meals. Electrolytes WNL (K 4.2), but BUN/Cr are elevated - initially 38/3.9, then it rose to 42/4.7 within 24 hrs...not a dialysis pt (yet). I understand why out-of-whack K+ can mess with blood sugar, but I don't understand a physiological reason for a pt to have such widely fluctuating blood sugars. Pt ended up getting four amps of D50 in a five hour period...BS was up to 250-300, then crashed again. We couldn't give pt any fluids b/c of all the fluid in lungs.

Pt's body ending having enough of that...before the fourth amp, pt became responsive only to sternal rub, Code White was called, pt went to a unit.

Can anyone shed some light? Any piece of the puzzle missing?

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Specializes in Med/Surg, Home Health.

Illness causes serum glucose to elevate, body responds by trying to decrease it and level it out. Sometimes it overcompensates and decreases too much. So the body then tries to compensate THAT and overshoots, which increases it too much. Its a bad cycle. SSI isnt widely used at our hospital anymore. Was this patient on steroids? Diabetes, etc. Having normal SERUM potassium may not necesarily mean that the K+ was ok. Cells move electrolytes in and out of the cells to try to fix the problem. I know Im not much help, but Id have to know more about the patient and right now Im "drugged up" on pain meds for an injury so this post may not even make any sense. lol. I hope the patient is ok

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Specializes in Cardiac, Acute/Subacute Rehab.

Pt is fine..spent some time on a unit, but is back on my PCU/Telemetry floor for a couple of days.

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Specializes in Critical Care.

Well if this patient is diabetic, (I'm guessing here, not a lot of info presented) and you said something about fluid in the lungs, I'd guess an infecious process may be going on. That definitely will throw glucose maintance off, at least in many patient populations I've seen. Meds can also have an effect but again, that's not really presented here. So based upon what you've stated, this would be my best guess.

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

Was pneumonia ruled out?

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Specializes in Med/Surg, Home Health.

CHF? The fluid buildup may have been an exac of CHF. Please give more info. Febrile? Edema?

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Specializes in Cardiac Telemetry, ED.

This patient sounds very sick. Diabetes in the setting of infection, adrenal insufficiency, fluid imbalances, multisystem organ failure, etc., can really be tough to manage, especially if the person was already a brittle diabetic.

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Specializes in Telemetry, CCU.

I know you only mentioned renal failure (which may be where the fluid in the lungs came from) but I'd be curious to see what the pt's liver enzymes were like. One thing that popped into mind was a pt I had in complete liver failure who's blood sugar quickly dropped to 20, d/t the body's lack of glucagon.

Otherwise I'd be inclined to go with the infection line of thinking; infection causes glucose regulation in the body to be out of whack, if the pt had pneumonia, that would contribute the high sugar. I'm still not sure about the low sugar though. I'm still looking forward to hearing other responses.

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Is the patient septic? I have seen this with severe sepsis.

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Specializes in Cardiac, Acute/Subacute Rehab.

A little more info...sorry for not including it before.

Pt came in with c/o near-syncope, was hypotensive...received 1/2NS at 125 ml/hr until her lungs started to fill up, then it was stopped (only got about 400cc). Liver enzymes, WBCs - everything was WNL. The only thing out of whack was BUN and Creatinine. Calcium was even normal (which we don't usually see...it's usually ALWAYS a little low). Temp wasn't elevated, and BP was 110s/60s and not fluctuating.

Did I miss anything? Thanks for your responses!! Keep them coming!! :specs:

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Specializes in ICU, Telemetry.

nephrosclerosis? I saw it in a patient who'd had long standing HTN, basically blew out their kidneys and sclerosed their glommeruli. BP plummeted and their sugars went all over the place because they couldn't excrete extra, nor were they active enough to burn any off.

Nephrosclerosis would cause the edema. How did their eyes look? You can get retinopathy with it.

Did they do a 24 hr creatinine clearance or a renin?

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Specializes in Hospital Education Coordinator.

you did not mention what the sliding scale insulin was - regular or one of the analogs? If regular, the ADA has clearly stated this mode is outdated and "not recommended". The RABBIT trial states "the use of SSI (regular) has NEVER been documented as effective". As a nurse and diabetic the lazy, I won't change no matter what you say attitude of sticking with regular SSI in the hospital is a pet peeve.

If the patient was on an analog plus Lantus there is more to consider. My experience is that few MD's outside endocrinology know how to order correctly. I even had one cardiologist tell me he did not care about the blood sugar, only the heart. How stupid is that?

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