help me figure out what happened :/

nurse2033, MSN, RN · Oct 30, 2012

Without knowing all the details of vitals and so on it is hard to make a guess. I think the most likely cause would be a blood clot causing rapid PE, stroke, or MI. What was the BP exactly? What was the heart rate at the time? What was the anticoagulant status? Were they on insulin? Certainly the D50 did not cause this. I would also want to see the labs. If your instructor was stumped don't feel bad, sometimes the clinical picture is a puzzle.

julz1980, BSN, RN · Oct 30, 2012

The only thing that I can think of is looking at how aggressive the renal failure was coupled with the hypertension. I think the timing of the dextrose administration was probably more coincidence than anything else. This may be one of those cases where the only way to really know is an autopsy.

I wouldn't stress about it too much. But it is very intriguing.

tokmom, BSN, RN · Oct 30, 2012

You say the vitals were 'normal' were they his/her normal? You might see a VS trend if you look back.

I second what the others say. Sounds like an acute HTN episode or PE. Will you find out? If you do, let us know.

akulahawkRN, ADN, RN, EMT-P · Oct 30, 2012

To me, it does not sound like the dextrose was the cause of the problem. I think it was probably coincidental more than anything else. The fact that the patient became more alert before slipping into unconsciousness tells me that the dextrose was beginning to do its job. With the SpO2 dropping and the blood pressure increasing, I can only think that what you were seeing was a compensatory mechanism for the increasing SpO2. It will probably truly take an autopsy to figure out what happened. Even then it's possible that the answer may never be known.

Jenni811, RN · Oct 30, 2012

It wasn't the dextrose. That is just bad timing...dextrose doesn't do that. It says to push over 5 minutes, but when i have a patient who is unresponsive d/t low blood sugars i don't have 5 minutes. Pharmacy tells us "Just push it!" Anything could have happened really, without knowing symptoms that led up to it its hard to say. Like did they complain of shortness of breath? chest pain? dizziness? etc. Patient's can code from alot of different scenerios....my guess is with a random drop in BS with other subtle things there was something else brewing.

I know you say BP are high, and i'll have students coming up to me scared out of their mind because their patient's blood pressure jumped from 130-150 systolic. it ok...Majority of doc's don't do anything unless its over 180. Certainly a BP at 130 or 140 won't cause a person to code. She could have thrown a clot, had an MI (Remember women have very subtle signs of MI that differ from men). Kidney disease wouldn't cause a code like that, unless they have lke stage 4 and are not being treated.

PE is a possibility but there would be other signs that go along with this. Low urine output wouldn't concern me too much at this point because she was scanned at 135 you say? With renal disease this isn't unheard of. Could she have been fluid overloaded? Sure...but wouldn't cause a code lik this. With a significant cardiac history she very well could have just gone into a bad rhythm. Like if she had prolonged QT interval or anything else that could cause a bad rhythm. Who knows?? But it doesn't sound as if it was the fault of anyone. Stuff like this happens and often go unanswered as to why it happened.

**LaurelRN, MSN · Oct 31, 2012

Though what everyone else has said could quite possibly seem feasible. I am more inclined to think (though without labs, trending vitals, and pt history, it's a guess) someone who is in renal failure quite often has electrolyte imbalances. What was the potassium? Mag? Calcium. I have seen more codes from electrolyte imbalances than I would care to. I do agree that the D50 IVP was just coincidence. Don't get too hung up on it- good luck

Jenni811, RN · Oct 31, 2012

Electrolyte imbalance is a good thought though. Like Laurel said...there are codes that are related to electrolyte imbalances. I work with post operative open heart patients, and i can tell you the one we keep an eye on the most (although all are important) is potassium. We have orders up the wazzzooo on wha to do when a potassium is every result you can think of. We also have PRN orders on medications to give if it is a certain level. Very similar to insulin and dextrose orders if you can imagine that.

Reason im getting at potassium is there is a correlation of insulin and potassium. I don't remember exactly what is is, but you say her blood sugar was 50 (NO history of diabetes) so she could have, for some reason, had an increase in insulin uptake or production. This can cause hypokalemia. (pretty sure it is hypo over hyper). Either way, Hypo and hyperkalemia can cause rhythm abnormalities. Not a good combination for someone who already has known cardiac history. I'd be curious to know her potassium, mag levels etc.

Good point Laurel :)

jadelpn, LPN, EMT-B · Oct 31, 2012

Threw a clot, sepsis, electrolytes off, Potassium, as noted on above post, acute renal failure-----or it was just a number of comorbitities that all came together for the perfect storm after surgery.

I am sorry you lost your patient. That is tough no matter what. ((hugs))

jadelpn, LPN, EMT-B · Oct 31, 2012

By the way, as an aside, when you are practicing in your own nursing career--elevated BUN and Creat, no urine output, and a FBS of 50--Rapid Response, this patient should be sent to a higher level of care. Just an opinion, but don't ever be afraid to ask for assistance of others if your patient has a lot of major issues that become critical quick.

Jenni811, RN · Nov 15, 2012

I don't think a higher level of care would be necessary on a med/surg unit for this type of patient. just because they have an elevated BUN doesn't mean they are a critical care patient. No urine output? yea thats not good, but not surprising since BUN/Cr is elevated. Doesn't warrant for higher level of care unless they were to become unstable. Also because thye had low blood sugar doesn't mean they need to be moved to higher level of care. I work on med/surg and we deal with low blood sugars, give them something to eat, maybe a little dextrose IV or some juice, check a few more blood sugars per protocol and call it good.

jadelpn, LPN, EMT-B · Nov 15, 2012

I don't think a higher level of care would be necessary on a med/surg unit for this type of patient. just because they have an elevated BUN doesn't mean they are a critical care patient. No urine output? yea thats not good, but not surprising since BUN/Cr is elevated. Doesn't warrant for higher level of care unless they were to become unstable. Also because thye had low blood sugar doesn't mean they need to be moved to higher level of care. I work on med/surg and we deal with low blood sugars, give them something to eat, maybe a little dextrose IV or some juice, check a few more blood sugars per protocol and call it good.

The second that a FBS is critically low (less than 50), with all the other co-morbitities, and they were unable to obtain labs (too many sticks and there's a limit), and no urine output with a critical high BUN and Creat I would have tried to head this off at the pass, but then the patient had a sudden more critical change, then yes, they would need a RRT, and hopefully an alternate level of care. Nurses should not be made to think that they have to do it all on their own. There are teams of people that can and do help. In this instance, it is not so much each individual issue, but all of the issues together.