Hypoglycemia Mystery Theater

[solneeshka, BSN, RN]

All nurses! Put on your sleuthing caps because I cannot figure this one out and it's driving me crazy. Had a pt last night who had a carotid stent placed yesterday afternoon. He had come out of the OR on neo with a MAP goal of 80-90 and still had the neo going. He has DM, day RN had not done the 17:00 accucheck by 19:00, so after report she did it. He was 219 and she slid him according to his scale, 2 units of novolog. We kind of laughed about how little that was, but if that's the scale, that's the scale. By then, he had already had a couple of sodas (diet) and some jello. He was complaining to me that he was hungry and his nutrition orders had advanced so he could have real food. It was about 20:30 by this time so I told him I would do his HS check before he ate and then I'd get him something to eat. He said he usually didn't slide himself at night, he just took his lantus, which was not on his orders. I explained all this to the NP, she said if that's what he does at home, let's do it here, skip the HS novolog and she added his home lantus to his MAR (31 units). I got him a turkey sandwich with mayo, a salad with French dressing, and another jello. He also drank 4 sodas over the next couple of hours (they were all diet). At some point after he ate, I gave him his lantus (probably 21:30 or so).

He had napped all day so of course he didn't want to go to sleep. He stayed up until well after 03:00 reading and watching movies on his kindle. Finally around 03:00, he had to pee (had great urine output all night), so I got him the urinal and then helped him move from the recliner to his bed. They were almost right next to each other, but he wasn't shaky or anything, he moved just fine.

All night I had been trying to wean him off the neo with mixed results. Not long after he went to bed, his BP started to rise so I turned it off. It actually started getting really high (mapping in the 100's, SBP 160s bumping up into the 180s sometimes). The NP and I noticed how now we seemed to have the opposite problem, but at least he didn't need the neo anymore and he'd be able to go home in the morning. I went in pretty frequently (maybe every half an hour) to have him reposition the arm with the art-line, just to make sure we were getting a good reading because he moved around a lot in his sleep. Also cycled the cuff enough to be confident the art-line was correlating. Around 05:30, I noticed blood all over his non-art-line arm and realized he had pulled out one of his PIVs. I cleaned it up and noticed it was all wet underneath, which I took to be from fluids that were no longer running into his arm. I cleaned his arm up, dried it off, and placed a dressing (although it really had already clotted off by then).

While I was in the bay, I noticed that his heart tracing was looking goofy. He had been bradycardic all night with bundle branch block, and really didn't deviate all night. But now I can only call it irregular and funny looking, BBB but odd. I called the NP who was in the SICU at the time, she said she'd be down in a minute to look at it, but in the meantime, draw a BMP on him. (She had not ordered PM labs because he'd just had them drawn when he arrived around 15:00 and everything looked good, we were expecting him to go home in the morning.) When I was drawing them from the art-line, I noticed that that arm felt wet, too. Then I noticed that all of him felt wet. Then I realized he really hadn't woken up much during all of this. I grabbed the accucheck and (are you ready for this)...14! Another nurse repeated it, again 14. I didn't even know it could register that low. We pushed an amp of D50 and I hung a 250mL bag of D10, we rechecked and he was 209. A resident had shown up coincidentally during this and called up for a SICU bed, asked us to get him up there asap. By then, the pt was already oriented. I explained to him what had happened and he just kind of nodded his head knowingly. (His HA1C had come back at about 8 and a half, so this was probably not his first hypoglycemic rodeo - just not well controlled.)

After the accuchecks but before the dextrose, his BP dropped fast, down to systolic 80s. After the D50, it was very nice, systolic 130s, mapping in the 80s, and his heart tracing was nice and steady (BBB, but even). Wait, I did turn the neo back on when I saw that low BP, I forgot about that. That might explain the improvement in BP, but not in the tracing. After I got back from dropping him off in the SICU, I looked up the BMP I had sent earlier. His K went from 4.2 at 15:00 to 3.2 at 05:50.

These are all the data points I can think of that might be relevant. So what the hey happened?!?!? How does someone with a BG of 219 who gets 2 units of novolog and 31 of lantus, and is eating like a cow, drop to 14?!?!

[blondy2061h, MSN, RN]

I'm willing to be at home he has more than a turkey sandwich, diet cola, and some jello throughout the day. While ideally the Lantus should be a dose that keeps someone's blood sugar steady over the course of 24 hours, a lot of type 2 diabetics are on doses high enough to drop them. If his A1c is 8.5 is average glucose is around 200. If he's taking the Lantus at bedtime after a large dinner, his bg might be 300-400 at home when he takes that same 30 units.

Also, what did the BMP glucose show? If he was on neo all night, his fingers might not be well perfused, which can result in an inaccurate result. Clinically, it definitely sounds like he was hypoglycemic, but maybe not 14

[solneeshka, BSN, RN]

I'm willing to be at home he has more than a turkey sandwich, diet cola, and some jello throughout the day. While ideally the Lantus should be a dose that keeps someone's blood sugar steady over the course of 24 hours, a lot of type 2 diabetics are on doses high enough to drop them. If his A1c is 8.5 is average glucose is around 200. If he's taking the Lantus at bedtime after a large dinner, his bg might be 300-400 at home when he takes that same 30 units.

Also, what did the BMP glucose show? If he was on neo all night, his fingers might not be well perfused, which can result in an inaccurate result. Clinically, it definitely sounds like he was hypoglycemic, but maybe not 14

The BMP glucose was "

[Esme12, ASN, BSN, RN]

What was the IVF infusing? Any dextrose in any of them?

[RockinChick66]

I've seen brittle DM pts that go up or down for no apparent reason. It's all just really weird sometimes. Glad I don't have DM.Sounds like your an awesome nurse and stayed on top of things.

[classicdame, MSN, EdD]

We never hold Lantus even for surgery or NPO because it provides the basal insulin needed for body function. People wrongly assume it acts like regular insulin. We never give rapid acting insulin at night and never without food. However, you stated the food was there so I am at a loss. I hope you talk to an endocrinologist about this, find out what went on, then report to all of us!!!

[nurseprnRN, BSN, RN]

Did we ever get the answer to this whodunnit -- or howdunnit?

[Bec7074]

I'm kinda perplexed by a few things in this scenario. First, why does someone who got only 1 cardiac stent need Neo???? Was this a cath-lab patient? He sounds super stable given that he's eating and peeing and reading his Kindle....not the kinda patient I would expect to need a pressor especially after such a small procedure in which many ppl are D/C'd the next day. Had he had an MI? We're his troponins elevated or was this a scheduled thing after a positive stress test? Also if he was bradycardic all night i would have thought Neo wasnt the best pressor. Maybe dopamine or levo could have helped. It just seems strange to me.

Regarding the sugar, maybe his body was in a higher metabolic state given the recent procedure and ?MI and therefore his body just handled his usual dose of Lantus differently.

[solneeshka, BSN, RN]

What was the IVF infusing? Any dextrose in any of them?

At the time of the incident, there were no IVF infusing because he was eating and drinking very well. They had been DCed.

[solneeshka, BSN, RN]

Did we ever get the answer to this whodunnit -- or howdunnit?

I haven't checked in to allnurses for a while, sorry! But the only resolution I got was that he did go home the next day, as scheduled. I assume that means there wasn't a concern for some unusual issue that might have caused it, but I don't know for sure.

[solneeshka, BSN, RN]

I'm kinda perplexed by a few things in this scenario. First, why does someone who got only 1 cardiac stent need Neo???? Was this a cath-lab patient? He sounds super stable given that he's eating and peeing and reading his Kindle....not the kinda patient I would expect to need a pressor especially after such a small procedure in which many ppl are D/C'd the next day. Had he had an MI? We're his troponins elevated or was this a scheduled thing after a positive stress test? Also if he was bradycardic all night i would have thought Neo wasnt the best pressor. Maybe dopamine or levo could have helped. It just seems strange to me.

Regarding the sugar, maybe his body was in a higher metabolic state given the recent procedure and ?MI and therefore his body just handled his usual dose of Lantus differently.

It wasn't a cardiac stent that he got, it was a carotid stent. He wasn't a Cath lab pt, although the stent was placed via groin access. He didn't need the neo to keep his BP safe or at baseline, it was because the surgical team wanted to maintain a certain minimum MAP for the first 24 hours post-op to help make sure the stent remained patent (they do this a lot at our facility, not sure if it's standard elsewhere). If memory serves, the desired MAP was higher than his baseline MAP (not unusual for what we see), which is why it's not unusual for these folks to be on neo drips post-op for the first night. In the morning, we titrate down until it's off and make sure they are maintaining their baseline BPs on their own before they go home. I did draw trops on him, they were all negative.

Left to my own devices to conclude what happened, my best guess is just that he's not well-controlled at home (as evidenced by his A1c) and his lantus dose might not be the right one. I don't know how long he's been on it. I hadn't thought about the stress of the procedure and hospitalization affecting his insulin differently, although it still seems like that would have brought his BG up, not down. Mystified.