Opinion re: managing low blood sugar?

[AHarri66]

With all the knowledge and experience out here, I'd like you folks' opinion regarding the following scenario:

I was day charge over this past weekend on my floor (Med/Surg-Tele). In taking report from night charge, I learned Saturday that one pt had an 0600 blood sugar of 48 and was given OJ w/sugar. I became a bit upset (this happens all the time) because 1.) our hospital has a standing protocol for all blood sugars below 70: give an amp of D50 and call the doc.; 2.) breakfast doesn't hit the floor until 0800 unless called for earlier, and it rarely is even in these cases; 3.) I've seen pts drop from 60's to 20's in 1/2 hour even with OJ and food, and you can't tell if this pt is one of those. Anyway, night charge basically brushed it off with "pt states she's always this low in the am," and "the OJ worked." (Pt was 68 one hour later.)

On Sunday, same pt was 42, and the same scenario occurred. Night charge and I got into a debate regarding blood sugar management, my opinion being I'd rather push the D50 and spend the rest of the day bringing her down, hers being that D50 was "overkill." (For the record, insulin was being adjusted incrementally.)

I was off Monday, but upon returning to work Wednesday I learned that Monday 0600 pt blood sugar was 36 & OJ was given (AGAIN) because she "was alert and talking." Within 1/2 hour, pt was unresponsive and CODED with a blood sugar of 22!!! Luckily, pt was brought around and as of Friday was still in ICU. Same night charge was on.

I'm angry because I believe we could have avoided putting this poor woman through this life-threatening situation, and I feel vindicated in my opinion because of what happened, but I suppose this could have been an isolated case....what do you think?

[baseline]

Originally posted by AHarri66

[b (For the record, insulin was being adjusted incrementally.)

[/b]

Sounds to me like they were working on the insulin dose, but we don't have enough info. Bottom line. Protocol was not followed.

[P_RN, ADN, RN]

Our protocal calls for a veniuncture recheck of a fingerstick under 70. In the interim juice/milk/cheese/crackers like 3rd shiftguy said.

If the recheck is still under 70 the doctor decides.

FYI I have also had a fingerstick come back at ONE! Done in the field, ER confirmed with venipuncture......mentally disabled alcoholic who they thought got some of his grandmothers insulin.....anyway they did the d50 several times and so did we.

[MishlB]

Originally posted by renerian

NO offense but I have hypoglycemia and I would want the OJ and not the D50.

Don't shoot the messenger.

renerian

I was going to say....D50 first? Just curious why this policy?

[nurseleigh]

I'm a bit confused. . .

Where I used to work we always started with OJ+sugar(LTC) and where I work now(hospital) we do the same.

Is this the old way of doing things and we just haven't been informed of better ways.

Our protocol calls for the OJ/sugar followed by diabetic snack in 10 minutes and call MD. If unable to swallow or under 40, D50. Recheck in 30 minutes.

Leigh

[Burnt Out, ASN, RN]

We have a hypoglycemic protocol that states if patient is alert and oriented to give 4 oz of juice, cola or milk and follow with peanut butter and crackers-then recheck FSBS in 20 minutes.

If they are lethargic or unresponsive, we give Glucagon if there is no IV access, then start an IV of D10W. If they have an IV they get 1/2 amp of D50, recheck FSBS and call MD (or something like this).

I am wondering with everyone else-why wasn't this patient's insulin dose @ hs adjusted?

[RNonsense]

Ours is similiar to ?burntout above. Hope the patient is ok after all this...

[AHarri66, BSN, RN]

Thanks all for your replies.

Firstly, the insulin was being adjusted each day, although it would almost seem like they were going in the wrong direction. Also, she coded from severe hypoglycemia, that's it. Chest compressions & the whole nine...not a "partial."

Secondly, I agree that intervening at a BS of 70 is a bit conservative. I would probably start at 60 or even 55, but be that as it may, our protocol states 70, and it's printed on the glucoscan sheet we use to record blood sugars. We are encouraged to start with juice followed by protein snacks as well, but for this low...36?? Like I said, I've seen a few people bottom out from 60 in under a half hour with juice and/or food. Also, how reliable is a pt's account at a BS that low? Most I've seen have been just a little "loopy."

I think I will be bringing this incident to the attention of the diabetes educator as suggested...although sometimes it seems like Nights at my hospital (no offense to 3rd shifters here!) operates in their own world, so I don't know what affect it would have.

Thanks again! I'll be checking in on my lady tomorrow, and I'll let you know how she's doing.

[baseline]

If I'm not mistaken, 70 is the newest reccomendation of the ADA. They are looking for tight glycemic control.

[vaughanmk]

After school and working on a pediatric diabetic floor as an aid. I would have start out with the OJ first also. But then again that is the protocol in all the facilities I've had clinicals. Since the protocol sayss to give D50 then that would be the correct thing to do. I would be just as mad as you are. The protocol is there for a reason. I just really hope the family doesn't find out that protocol was not followed because the entire ICU stay will be on that nurse. She didn't follow the rules and could be held responsible.

[TeresaRN2b]

Originally posted by 3rdShiftGuy

I think the point is that they aren't following hospital policy.

That said, our hospital protocol is to start with juice for a rapid rise in glucose out of the danger level, followed by a more slower released snack like skim milk and peanut butter and crackers. But we don't intervene until they fall below 60. Not having the protocols near me, I can't say exactly what we do, but I'm sure this is it.

If the patient is still alert and not overly symptomatic I go with the juice.

We can't push D50 without an MD order anyway, so if they can swallow, I don't waste time. I still call the MD of course.

I am still a student nurse (well soon to be student nurse), but I have an IDDM child. He was diagnosed 5 years ago. This is exactly the protocal our endocrinologist has given us. I tend to disagree with the post below that it is easier to chase a high blood sugar. I personally would be very upset if a nurse/doctor pushed D50 without trying the OJ and snack first. When the blood sugar shoots back up and your chasing it with insulin all day and then rebound with another low not the best solution to me. Our protocal that our endo gives us is to recheck blood sugar 15 minutes after the first snack. If still low another snack and recheck again in 15 minutes. If then after the second snack blood sugar is not up then we will take more aggressive action on raising blood sugar. Anyway, probably shouldn't be throwing my two cents in here since I don't have that much schooling under me, but I have dealt with adjusting insulin for 5 years now so the post caught my attention. I always try and read as much as I can on it.

[BrandieRNq]

WE ARE THE CRITICAL THINKING NURSES. You know, the ones' taught to questions a doctors order???

Whatever the PROTOCOL...we use our brains! Who says the protocol is right? Will the Judge think the protocol is law?

You do what is right for the patient based on your education, experience and lets hope, "common sense"!

[igloorn93]

I too would be curious as to why protocol wasn't followed correctly. Perhaps a new clearer policy can be developed from this case. Our policy states to get serum confirmations for BS